Provider Demographics
NPI:1104819259
Name:GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Entity type:Organization
Organization Name:GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-832-7790
Mailing Address - Street 1:PO BOX 62946
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2946
Mailing Address - Country:US
Mailing Address - Phone:410-494-7607
Mailing Address - Fax:610-925-7387
Practice Address - Street 1:464 MAIN ST
Practice Address - Street 2:HERITAGE HALL EAST
Practice Address - City:AGAWAM
Practice Address - State:MA
Practice Address - Zip Code:01001
Practice Address - Country:US
Practice Address - Phone:413-786-8000
Practice Address - Fax:413-789-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75866207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9770917Medicaid
MAY10347Medicare ID - Type UnspecifiedGROUP NUMBER