MEDICARE: GENESIS MEDICA URGENT CARE 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	261QU0200X	Urgent Care Clinic/Center	036883	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1912927658	OTHER	CT	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1710497607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS MEDICA URGENT CARE GROUP LLC

Provider Business Mailing Address
First Line	:	1427 CHAPEL ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-4403
Country	:	US
Telephone Number	:	203-865-3880
Fax Number	:

Provider Business Practice Location Address
First Line	:	1427 CHAPEL ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-4403
Country	:	US
Telephone Number	:	203-865-3880
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. TERRY CHOSZCZYK
Credential	:
Telephone Number	:	203-865-3880

Provider Enumeration Date	:	10/04/2017
Last Update Date	:	06/16/2018

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