Provider Demographics
NPI:1356572358
Name:THE GENESIS PROJECT, PLC
Entity type:Organization
Organization Name:THE GENESIS PROJECT, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-294-9890
Mailing Address - Street 1:1601 BOYSON SQUARE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:HIAWATHA
Mailing Address - State:IA
Mailing Address - Zip Code:52233-2311
Mailing Address - Country:US
Mailing Address - Phone:319-294-9890
Mailing Address - Fax:319-294-9896
Practice Address - Street 1:1601 BOYSON SQUARE DR
Practice Address - Street 2:SUITE B
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2311
Practice Address - Country:US
Practice Address - Phone:319-294-9890
Practice Address - Fax:319-294-9896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-07
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27190261QU0200X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAE92171Medicare UPIN