Healthcare Provider Details

I. General information

NPI: 1447510714
Provider Name (Legal Business Name): GENESIS ELDER CARE PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CIVIC AVE
SALISBURY MD
21804-4599
US

IV. Provider business mailing address

PO BOX 42738
TOWSON MD
21284-2738
US

V. Phone/Fax

Practice location:
  • Phone: 410-749-1466
  • Fax:
Mailing address:
  • Phone: 410-494-7607
  • Fax: 610-925-7387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberR188822
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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