Provider Demographics
NPI:1205304888
Name:ASCENSION MEDICAL GROUP GENESYS
Entity type:Organization
Organization Name:ASCENSION MEDICAL GROUP GENESYS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMMLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-424-2136
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2136
Mailing Address - Fax:
Practice Address - Street 1:1096 S BELSAY RD STE J
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1948
Practice Address - Country:US
Practice Address - Phone:810-715-0803
Practice Address - Fax:810-715-0824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty