Provider Demographics
NPI:1457517138
Name:GENESIS MEDICAL GROUP, LLC.
Entity Type:Organization
Organization Name:GENESIS MEDICAL GROUP, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATION
Authorized Official - Prefix:MR
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:503-699-1911
Mailing Address - Street 1:16679 BOONES FERRY RD STE 215
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4368
Mailing Address - Country:US
Mailing Address - Phone:503-699-1911
Mailing Address - Fax:503-699-1912
Practice Address - Street 1:16679 BOONES FERRY RD STE 215
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4368
Practice Address - Country:US
Practice Address - Phone:503-699-1911
Practice Address - Fax:503-699-1912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1355445-0335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500608071Medicaid
OR081911000OtherBLUE CROSS BLUE SHIELD
OR081911000OtherBLUE CROSS BLUE SHIELD