Healthcare Provider Details

I. General information

NPI: 1104819259
Provider Name (Legal Business Name): GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 MAIN ST HERITAGE HALL EAST
AGAWAM MA
01001
US

IV. Provider business mailing address

PO BOX 62946
BALTIMORE MD
21264-2946
US

V. Phone/Fax

Practice location:
  • Phone: 413-786-8000
  • Fax: 413-789-1099
Mailing address:
  • Phone: 410-494-7607
  • Fax: 610-925-7387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number75866
License Number StateMA

VIII. Authorized Official

Name: ERIC SHAPIRO
Title or Position: VP, CONTROLLER
Credential:
Phone: 410-832-7790