MEDICARE: GENESIS ELDERCARE PHYSICIAN SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	75866	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104819259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS ELDERCARE PHYSICIAN SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 62946
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21264-2946
Country	:	US
Telephone Number	:	410-494-7607
Fax Number	:	610-925-7387

Provider Business Practice Location Address
First Line	:	464 MAIN ST
Second Line	:	HERITAGE HALL EAST
City	:	AGAWAM
State	:	MA
Zip	:	01001
Country	:	US
Telephone Number	:	413-786-8000
Fax Number	:	413-789-1099

Authorized Official
Title or Position	:	VP, CONTROLLER
Name	:	ERIC SHAPIRO
Credential	:
Telephone Number	:	410-832-7790

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	08/05/2019

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