Basic Information
| Provider Information | |||||||||
| NPI: | 1972542264 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GENESIS MEDICAL CENTER DAVENPORT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1227 E RUSHOLME ST | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213402 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Practice Location | |||||||||
| Address1: | 1227 E RUSHOLME ST | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213402 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 5634216513 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | N | Hospital Units | Psychiatric Unit | 273Y00000X | N | Hospital Units | Rehabilitation Unit | 276400000X | N | Hospital Units | Rehabilitation, Substance Use Disorder Unit | 341600000X | IA | N | Transportation Services | Ambulance | 282N00000X | IA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0109710 | 05 | IA | MEDICAID | 0197558 | 05 | IA | MEDICAID | 370062800 | 01 | DEPT OF LABOR | OTHER | H80 | 01 | MIDLANDS CHOICE | OTHER | 0143222 | 05 | IA | MEDICAID | 0253484 | 05 | IA | MEDICAID | 3310060 | 05 | IA | MEDICAID | 0308577 | 05 | IA | MEDICAID | 0310037 | 05 | IA | MEDICAID | 0600338 | 05 | IA | MEDICAID | 0106344 | 05 | IA | MEDICAID | 009755 | 01 | HEALTH ALLIANCE UB | OTHER | 60033 | 01 | IA | BLUE CROSS ACUTE | OTHER |