Basic Information
| Provider Information | |||||||||
| NPI: | 1902186364 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | GENESIS EMERGENCY PHYSICIAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD STE L10 | ||||||||
| Address2: | |||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559200 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 1227 E RUSHOLME ST | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634216610 | ||||||||
| FaxNumber: | 5634217719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2011 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE / CFO | ||||||||
| AuthorizedOfficialTelephone: | 5634216513 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0496083 | 05 | IA | MEDICAID |