Provider Demographics
NPI:1760412068
Name:GENESIS HEALTH SYSTEM
Entity Type:Organization
Organization Name:GENESIS HEALTH SYSTEM
Other - Org Name:INTEGRATIVE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLEINSCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-421-6513
Mailing Address - Street 1:2526 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-5016
Mailing Address - Country:US
Mailing Address - Phone:309-792-7063
Mailing Address - Fax:309-764-9326
Practice Address - Street 1:2526 41ST ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-5016
Practice Address - Country:US
Practice Address - Phone:309-792-7063
Practice Address - Fax:309-764-9326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002883103T00000X
IL038007310111N00000X
IL164002086133V00000X
IL036062709207Q00000X
IL085001982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206738Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER