Provider Demographics
NPI:1063456424
Name:GENESIS MEDICAL CENTER OF KENOSHA, S.C.
Entity Type:Organization
Organization Name:GENESIS MEDICAL CENTER OF KENOSHA, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRETTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-652-3500
Mailing Address - Street 1:1020 35TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-1902
Mailing Address - Country:US
Mailing Address - Phone:262-652-3500
Mailing Address - Fax:262-925-8353
Practice Address - Street 1:1020 35TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1902
Practice Address - Country:US
Practice Address - Phone:262-652-3500
Practice Address - Fax:262-925-8353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21301500Medicaid
WI21301500Medicaid