Healthcare Provider Details

I. General information

NPI: 1366050007
Provider Name (Legal Business Name): GENERATION CLINICAL PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 AUERBACH PL
GLEN CARBON IL
62034-1596
US

IV. Provider business mailing address

PO BOX 14713
BELFAST ME
04915-4042
US

V. Phone/Fax

Practice location:
  • Phone: 314-925-0903
  • Fax: 314-764-2279
Mailing address:
  • Phone: 314-925-0903
  • Fax: 314-764-2279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MAE LIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-925-0903