Provider Demographics
NPI:1972856854
Name:GENESIS MEDICAL CENTER, ALEDO
Entity Type:Organization
Organization Name:GENESIS MEDICAL CENTER, ALEDO
Other - Org Name:GENESIS HEALTH GROUP, SEPCIALTY CLINIC, ALEDO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:CROPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-421-6510
Mailing Address - Street 1:1007 NW 3RD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-1317
Mailing Address - Country:US
Mailing Address - Phone:309-582-3701
Mailing Address - Fax:309-582-3737
Practice Address - Street 1:1007 NW 3RD ST STE 100
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-1317
Practice Address - Country:US
Practice Address - Phone:309-582-3701
Practice Address - Fax:309-582-3737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-17
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========401Medicaid
IL=========001Medicaid