1740538115 NPI number — GENESIS MEDICAL GROUP, LLC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740538115 NPI number — GENESIS MEDICAL GROUP, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESIS MEDICAL GROUP, LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740538115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16679 BOONES FERRY RD
Provider Second Line Business Mailing Address:
215
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035-4365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-699-1911
Provider Business Mailing Address Fax Number:
503-699-1912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 NW 18TH AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97209-2516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-699-1911
Provider Business Practice Location Address Fax Number:
503-699-1912
Provider Enumeration Date:
08/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
WYATT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DIRECTOR OF OPERATION
Authorized Official Telephone Number:
503-699-1911

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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