Provider Demographics
NPI:1801182753
Name:GENESIS HEALTH SYSTEM
Entity Type:Organization
Organization Name:GENESIS HEALTH SYSTEM
Other - Org Name:GENESIS MEMORY CLINIC, ILLINI CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE / CFO
Authorized Official - Prefix:
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 1:865 LINCOLN RD
Mailing Address - Street 2:SUITE L10
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-4190
Mailing Address - Country:US
Mailing Address - Phone:563-355-9200
Mailing Address - Fax:563-355-3419
Practice Address - Street 1:855 ILLINI DR
Practice Address - Street 2:SUITE 202
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-2907
Practice Address - Country:US
Practice Address - Phone:309-281-2630
Practice Address - Fax:309-281-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty