Provider Demographics
NPI:1225018211
Name:GENESIS HEALTH SYSTEM
Entity Type:Organization
Organization Name:GENESIS HEALTH SYSTEM
Other - Org Name:GENESIS HEALTH GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
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 1:865 LINCOLN RD
Mailing Address - Street 2:SUITE L10
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-4190
Mailing Address - Country:US
Mailing Address - Phone:563-355-9191
Mailing Address - Fax:563-355-3419
Practice Address - Street 1:865 LINCOLN RD
Practice Address - Street 2:SUITE L10
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-4190
Practice Address - Country:US
Practice Address - Phone:563-355-9191
Practice Address - Fax:563-355-3419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207Q00000X, 207R00000X, 207RE0101X, 207V00000X, 208000000X
IL207Q00000X, 207R00000X, 207V00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10121664OtherBC/BS OF IL
IL90000625OtherBC/BS OF IL
IA0496083Medicare PIN
IL90000625OtherBC/BS OF IL
IA0496083Medicare PIN