Provider Demographics
NPI:1427440403
Name:GENESIS REHAB
Entity type:Organization
Organization Name:GENESIS REHAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRONCHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-345-3837
Mailing Address - Street 1:1691 YALE PL
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-1115
Mailing Address - Country:US
Mailing Address - Phone:608-345-3837
Mailing Address - Fax:
Practice Address - Street 1:1691 YALE PL
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-1115
Practice Address - Country:US
Practice Address - Phone:608-345-3837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3840314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1590869Other1590869