Healthcare Provider Details

I. General information

NPI: 1194774943
Provider Name (Legal Business Name): GENESIS ELDER CARE PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 COMMONWEALTH AVENUE
WARWICK RI
02886-2707
US

IV. Provider business mailing address

PO BOX 42738
TOWSON MD
21284-2738
US

V. Phone/Fax

Practice location:
  • Phone: 401-739-4241
  • Fax: 401-732-3358
Mailing address:
  • Phone: 860-687-3629
  • Fax: 860-687-3622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNPP37084
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARGARET JEAN BAKER
Title or Position: DIR OF BUS OPS
Credential:
Phone: 410-494-7607