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General NPI Number Information
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NPI Number | 1104819259
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Entity Type | Organization
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Legal Business Name | GENESIS ELDERCARE PHYSICIAN SERVICES LLC
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Dates
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Enumeration Date | 08/24/2005
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Last Update Date | 08/05/2019
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Provider Practice Location Address
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Address Line | 464 MAIN ST HERITAGE HALL EAST
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City | AGAWAM
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State | MA
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Zip | 01001
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Country | US
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Telephone | 413-786-8000
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Fax | 413-789-1099
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Provider Business Mailing Address
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Address Line | PO BOX 62946
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City | BALTIMORE
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State | MD
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Zip | 21264-2946
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Country | US
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Telephone | 410-494-7607
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Fax | 610-925-7387
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Authorized Official
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Title or Position | VP, CONTROLLER
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Name | ERIC SHAPIRO
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Credential |
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Telephone | 410-832-7790
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | 75866
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License Number State | MA
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