Provider Demographics
NPI:1407834039
Name:GENESIS MEDICAL, INC.
Entity Type:Organization
Organization Name:GENESIS MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:336-627-4600
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27289-5018
Mailing Address - Country:US
Mailing Address - Phone:336-623-5010
Mailing Address - Fax:336-623-5091
Practice Address - Street 1:113 N PIERCE STREET
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5018
Practice Address - Country:US
Practice Address - Phone:336-623-5010
Practice Address - Fax:336-623-5091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009134981Medicaid
NC0493IOtherBCBSNC
NC7700081Medicaid
GA8209185OtherUNITED HEALTH CARE
UT8209185OtherUNITED HEALTH CARE
TX8209185OtherUNITED HEALTH CARE
UT8209185OtherUNITED HEALTH CARE
NC0581550001Medicare ID - Type Unspecified