Provider Demographics
NPI:1790712073
Name:GENESIS MEDICAL GROUP II, INC
Entity Type:Organization
Organization Name:GENESIS MEDICAL GROUP II, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATION
Authorized Official - Prefix:MR
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:503-231-1529
Mailing Address - Street 1:10802 SE WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3118
Mailing Address - Country:US
Mailing Address - Phone:503-231-1529
Mailing Address - Fax:503-231-7805
Practice Address - Street 1:10802 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3118
Practice Address - Country:US
Practice Address - Phone:503-231-1529
Practice Address - Fax:503-231-7805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR123617Medicaid
OR123617Medicaid