Healthcare Provider Details

I. General information

NPI: 1609180926
Provider Name (Legal Business Name): GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6508 DEER POINTE DR STE A
SALISBURY MD
21804
US

IV. Provider business mailing address

PO BOX 62946
BALTIMORE MD
21264-2946
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-1957
  • Fax: 410-543-8492
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 Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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