1861558512 NPI number — RM GENESIS HEALTHCARE

Table of content: (NPI 1861558512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861558512 NPI number — RM GENESIS HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RM GENESIS HEALTHCARE
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:
6
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:
1861558512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4518 W MARKET ST STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27407-1543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-235-4022
Provider Business Mailing Address Fax Number:
336-235-4023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4518 W MARKET ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27407-1543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-235-4022
Provider Business Practice Location Address Fax Number:
336-235-4023
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
ROOSEVELT
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
336-235-4022

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  2930 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 085AM . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 617755 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 264096200 . This is a "FEDERAL WORKERS COMP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 42898 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 617755 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89085AM , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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