Healthcare Provider Details

I. General information

NPI: 1801215041
Provider Name (Legal Business Name): GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 TENDERFOOT HILL RD # T
COLORADO SPRINGS CO
80906
US

IV. Provider business mailing address

PO BOX 62946
BALTIMORE MD
21264-2946
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-1957
  • Fax: 410-543-2951
Mailing address:
  • Phone: 410-494-7607
  • Fax: 610-925-7387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ERIC SHAPIRO
Title or Position: VICE PRESIDENT
Credential:
Phone: 410-832-7790