Provider Demographics
NPI:1013214014
Name:GENESIS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:GENESIS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATION
Authorized Official - Prefix:MR
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:503-699-1911
Mailing Address - Street 1:16679 BOONES FERRY RD STE 215
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4368
Mailing Address - Country:US
Mailing Address - Phone:503-699-1911
Mailing Address - Fax:503-699-1912
Practice Address - Street 1:10802 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3118
Practice Address - Country:US
Practice Address - Phone:503-699-1911
Practice Address - Fax:503-699-1912
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-28
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500608071Medicaid