Provider Demographics
NPI:1164415196
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:VP, AREA CONTROLLER
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:610-925-7387
Practice Address - Street 1:1 EMERSON DR
Practice Address - Street 2:KIMBERLY HALL NORTH
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095
Practice Address - Country:US
Practice Address - Phone:860-688-6443
Practice Address - Fax:860-688-5230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
CT207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004195021Medicaid
CT004126919Medicaid