Provider Demographics
NPI:1033535828
Name:GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-832-7790
Mailing Address - Street 1:PO BOX 62946
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2946
Mailing Address - Country:US
Mailing Address - Phone:410-494-7607
Mailing Address - Fax:
Practice Address - Street 1:16605 CHESTNUT GLEN PL
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245
Practice Address - Country:US
Practice Address - Phone:410-543-1957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-17
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RG0300X
KY0858289.09363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty