NPIMap

Organization Active NPI

Genesis Eldercare Physician Services LLC

  • Geriatric Medicine (Internal Medicine) Physician
  • Agawam, MA
National Provider Identifier
1104819259
Registry record updated Aug 5, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Medicine (Internal Medicine) PhysicianTaxonomy code 207RG0300X
License
75866 Issued in MA
Legal business name
GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Practice address
464 Main St
Heritage Hall East
Agawam, MA 01001
Phone
(413) 786-8000
Fax
(413) 789-1099
NPI assigned
Aug 24, 2005
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Eric Shapiro
Title
VP, Controller
Phone
(410) 832-7790

Other NPIs with the same Medicare PAC ID 14

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 14

Practitioners 47

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 47

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040824000702 MA Part B Supplier - Clinic/Group Practice 9830002534 Receives reassigned benefits from 3 practitioners
Practice locations: Lawrence, MA; Lowell, MA; Leominster, MA; Medford, MA; Milford, MA; North Andover, MA; North Reading, MA; Oxford, MA…

National Provider Directory

National Provider Directory

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Geriatric Medicine (Internal Medicine) PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RG0300X 75866 MA Primary

Addresses

NPPES NPI Registry

Primary practice location

464 Main St
Heritage Hall East
Agawam, MA 01001

Mailing address

PO Box 62946
Baltimore, MD 21264-2946
Phone (410) 494-7607

Other identifiers 1

NPPES NPI Registry
IdentifierTypeStateIssuer
9770917MedicaidMA

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Aug 5, 2019.

{
    "created_epoch": "1124841600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1564963200000",
    "number": "1104819259",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 62946",
            "city": "BALTIMORE",
            "state": "MD",
            "postal_code": "212642946",
            "telephone_number": "410-494-7607",
            "fax_number": "610-925-7387"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "464 MAIN ST",
            "address_2": "HERITAGE HALL EAST",
            "city": "AGAWAM",
            "state": "MA",
            "postal_code": "01001",
            "telephone_number": "413-786-8000",
            "fax_number": "413-789-1099"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GENESIS ELDERCARE PHYSICIAN SERVICES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-24",
        "last_updated": "2019-08-05",
        "status": "A",
        "authorized_official_last_name": "SHAPIRO",
        "authorized_official_first_name": "ERIC",
        "authorized_official_title_or_position": "VP, CONTROLLER",
        "authorized_official_telephone_number": "410-832-7790"
    },
    "taxonomies": [
        {
            "code": "207RG0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Geriatric Medicine",
            "state": "MA",
            "license": "75866",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9770917",
            "state": "MA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Agawam, MA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 5, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.