Healthcare Provider Details

I. General information

NPI: 1790920288
Provider Name (Legal Business Name): GENESIS ELDERCARE PHYSICIAN SERVICES I LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HAYWOOD AVE
RUTLAND VT
05701-4832
US

IV. Provider business mailing address

801 N SALISBURY BLVD SUITE 201
SALISBURY MD
21801-3624
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-1957
  • Fax:
Mailing address:
  • Phone: 410-543-1957
  • Fax:

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 Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CATHERINE TREGOE
Title or Position: DIRECTOR OF BUSINESS OPERATIONS
Credential:
Phone: 410-543-8870