Provider Demographics
NPI:1598081739
Name:GENESIS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:GENESIS MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-454-4788
Mailing Address - Street 1:945 BETHESDA DR STE 200
Mailing Address - Street 2:
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:
Practice Address - Street 1:401 LINCOLN PARK DR
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1033
Practice Address - Country:US
Practice Address - Phone:740-342-5107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-13
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health