Healthcare Provider Details

I. General information

NPI: 1154988079
Provider Name (Legal Business Name): GENESIS WELLNESS MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2019
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 KUSER RD STE C1
HAMILTON NJ
08619-3830
US

IV. Provider business mailing address

1544 KUSER RD STE C1
HAMILTON NJ
08619-3830
US

V. Phone/Fax

Practice location:
  • Phone: 609-585-3640
  • Fax: 609-585-3620
Mailing address:
  • Phone: 609-585-3640
  • Fax: 609-585-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALFRED R TAWADROUS
Title or Position: MD/MEDICAL DIRECTOR
Credential:
Phone: 347-677-3022