Provider Demographics
NPI:1740538115
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:
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:J
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
Mailing Address - Street 2:215
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4365
Mailing Address - Country:US
Mailing Address - Phone:503-699-1911
Mailing Address - Fax:503-699-1912
Practice Address - Street 1:1515 NW 18TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2516
Practice Address - Country:US
Practice Address - Phone:503-699-1911
Practice Address - Fax:503-699-1912
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS MEDICAL GROUP, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier