MEDICARE: GENESIS MEDICAL GROUP, 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	335E00000X	Prosthetic/Orthotic Supplier	1355445-0	OR

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
2	081911000	OTHER	OR	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1457517138
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS MEDICAL GROUP, LLC.

Provider Business Mailing Address
First Line	:	16679 BOONES FERRY RD STE 215
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4368
Country	:	US
Telephone Number	:	503-699-1911
Fax Number	:	503-699-1912

Provider Business Practice Location Address
First Line	:	16679 BOONES FERRY RD STE 215
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4368
Country	:	US
Telephone Number	:	503-699-1911
Fax Number	:	503-699-1912

Authorized Official
Title or Position	:	DIRECTOR OF OPERATION
Name	:	MR. WYATT JAMES BROWN
Credential	:	CPED
Telephone Number	:	503-699-1911

Provider Enumeration Date	:	08/01/2008
Last Update Date	:	04/03/2012

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Directions to “GENESIS MEDICAL GROUP, LLC. ” Practice Location

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