Provider Demographics
NPI:1285653451
Name:GENESIS ELDER CARE PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:GENESIS ELDER CARE PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, 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 42738
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21284-2738
Mailing Address - Country:US
Mailing Address - Phone:410-494-7607
Mailing Address - Fax:610-925-7387
Practice Address - Street 1:161 BAKERS RIDGE RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1459
Practice Address - Country:US
Practice Address - Phone:304-285-0692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001777Medicaid
WV3810001777Medicaid