Provider Demographics
NPI:1437218526
Name:GENESIS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:GENESIS MEDICAL GROUP LLC
Other - Org Name:CROOKSVILLE FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSIST, TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MASTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-454-4637
Mailing Address - Street 1:945 BETHESDA DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1880
Mailing Address - Country:US
Mailing Address - Phone:740-454-4788
Mailing Address - Fax:740-450-6157
Practice Address - Street 1:712 CHINA STREET
Practice Address - Street 2:CROOKSVILLE FAMILY CLINIC INC.
Practice Address - City:CROOKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43731-1124
Practice Address - Country:US
Practice Address - Phone:740-982-6872
Practice Address - Fax:740-982-5551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2270313Medicaid
OH363849Medicare PIN
OH9296921Medicare PIN