Provider Demographics
NPI:1477576304
Name:GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, CONTROLLER
Authorized Official - Prefix:MR
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 62946
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2946
Mailing Address - Country:US
Mailing Address - Phone:410-494-7607
Mailing Address - Fax:610-925-7387
Practice Address - Street 1:9 HAYWOOD AVE
Practice Address - Street 2:MOUNTAIN VIEW CENTER
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-775-0007
Practice Address - Fax:802-775-6895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RG0300X
VT101-0025776363LA2200X
VT101-0019819363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1104819259Medicaid
VTNG0092Medicare ID - Type Unspecified