Healthcare Provider Details

I. General information

NPI: 1245579762
Provider Name (Legal Business Name): GENESIS ELDER CARE PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2013
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: 410-543-2951
Mailing address:
  • Phone: 410-494-7607
  • Fax: 610-925-7387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC196800
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberC196800
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC196800
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberC196800
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberC196800
License Number StateID
# 7
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberC196800
License Number StateID
# 8
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberC196800
License Number StateID

VIII. Authorized Official

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