Provider Demographics
NPI:1205860400
Name:GENESIS HEALTH SYSTEM
Entity Type:Organization
Organization Name:GENESIS HEALTH SYSTEM
Other - Org Name:GENESIS CONVENIENT CARE DAVENPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-421-6513
Mailing Address - Street 1:PO BOX 765
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-0765
Mailing Address - Country:US
Mailing Address - Phone:563-355-9200
Mailing Address - Fax:563-355-3415
Practice Address - Street 1:1520 W 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-2459
Practice Address - Country:US
Practice Address - Phone:563-421-3800
Practice Address - Fax:563-421-3810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
66023OtherHEALTH ALLIANCE
IA08691OtherBLUE CROSS/BLUE SHIELD IA
387175OtherHEALTHLINK
IA0106OtherJDHC
IA0243972Medicaid
903630OtherHARVARD PILGRIM
387175OtherHEALTHLINK
IA0106OtherJDHC
IA=========401Medicaid
=========014OtherTRICARE