Provider Demographics
NPI:1922012764
Name:GENESIS HEALTH SYSTEM
Entity Type:Organization
Organization Name:GENESIS HEALTH SYSTEM
Other - Org Name:GENESIS FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-421-4400
Mailing Address - Street 1:1345 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1844
Mailing Address - Country:US
Mailing Address - Phone:563-421-4400
Mailing Address - Fax:563-421-4449
Practice Address - Street 1:1345 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1844
Practice Address - Country:US
Practice Address - Phone:563-421-4400
Practice Address - Fax:563-421-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0495747Medicaid
IA0495952Medicaid
IA0495952Medicaid
IAI17958Medicare ID - Type Unspecified