Provider Demographics
NPI:1760434658
Name:GENESIS HEALTH SYSTEM
Entity Type:Organization
Organization Name:GENESIS HEALTH SYSTEM
Other - Org Name:GENESIS MEDICAL CENTER - PHYSICAL MEDICINE AND REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-421-6513
Mailing Address - Street 1:PO BOX 310102
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50331-0001
Mailing Address - Country:US
Mailing Address - Phone:563-421-4380
Mailing Address - Fax:563-421-4389
Practice Address - Street 1:1351 W CENTRAL PARK AVE
Practice Address - Street 2:420
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1853
Practice Address - Country:US
Practice Address - Phone:563-421-4380
Practice Address - Fax:563-421-4389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0401944Medicaid
IA0401944Medicaid