Provider Demographics
NPI:1740439603
Name:SECOND GENESIS
Entity type:Organization
Organization Name:SECOND GENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:J.
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCGUINNESS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:301-563-1545
Mailing Address - Street 1:8611 2ND AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3372
Mailing Address - Country:US
Mailing Address - Phone:301-563-1545
Mailing Address - Fax:301-563-1546
Practice Address - Street 1:4017 MINNESOTA AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3541
Practice Address - Country:US
Practice Address - Phone:202-388-8570
Practice Address - Fax:202-388-3523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC111507A-Y-170261QR0405X
DC111507A-171261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1316115454Medicaid
MD1003084146Medicaid
MD1053589242Medicaid
DC1790766855Medicaid