MEDICARE: GENESIS FAMILY CARE MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	G34101	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467640409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS FAMILY CARE MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	1101 N SEPULVEDA BLVD STE 102
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5962
Country	:	US
Telephone Number	:	310-545-6627
Fax Number	:	310-545-0352

Provider Business Practice Location Address
First Line	:	1101 N SEPULVEDA BLVD STE 102
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-5962
Country	:	US
Telephone Number	:	310-545-6627
Fax Number	:	310-545-0352

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RONALD RUBY J.
Credential	:
Telephone Number	:	310-545-6627

Provider Enumeration Date	:	10/03/2007
Last Update Date	:	05/29/2015

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