Basic Information
| Provider Information | |||||||||
| NPI: | 1932757333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4028 | ||||||||
| Address2: | |||||||||
| City: | ROCK ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612044028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559200 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 4455 E 56TH ST | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528072995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633552577 | ||||||||
| FaxNumber: | 5633554015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2019 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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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 | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.