Healthcare Provider Details

I. General information

NPI: 1477576304
Provider Name (Legal Business Name): GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HAYWOOD AVE MOUNTAIN VIEW CENTER
RUTLAND VT
05701
US

IV. Provider business mailing address

PO BOX 62946
BALTIMORE MD
21264-2946
US

V. Phone/Fax

Practice location:
  • Phone: 802-775-0007
  • Fax: 802-775-6895
Mailing address:
  • Phone: 410-494-7607
  • Fax: 610-925-7387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number101-0025776
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number101-0019819
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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