Provider Demographics
NPI:1942590658
Name:GENESIS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:GENESIS MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO OF PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-454-4788
Mailing Address - Street 1:945 BETHESDA DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1880
Mailing Address - Country:US
Mailing Address - Phone:740-454-4788
Mailing Address - Fax:
Practice Address - Street 1:2854 BELL ST STE B
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1721
Practice Address - Country:US
Practice Address - Phone:740-588-1091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies