NPIMap

Organization Active NPI

Genesis Eldercare Physician Services LLC

  • Geriatric Medicine (Internal Medicine) Physician
  • Windsor, CT
National Provider Identifier
1164415196
Registry record updated Aug 5, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Medicine (Internal Medicine) PhysicianTaxonomy code 207RG0300X
Legal business name
GENESIS ELDERCARE PHYSICIAN SERVICES LLC
Practice address
1 Emerson Dr
Kimberly Hall North
Windsor, CT 06095
Phone
(860) 688-6443
Fax
(860) 688-5230
NPI assigned
Aug 24, 2005
Last updated
Aug 5, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 5, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Eric Shapiro
Title
VP, Area Controller
Phone
(410) 832-7790

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X NU
Geriatric Medicine (Internal Medicine) Physician 207RG0300X CT Primary

Addresses

Primary practice location

1 Emerson Dr
Kimberly Hall North
Windsor, CT 06095

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
004195021MedicaidCT
004126919MedicaidCT

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031110000130 CT Part B Supplier - Clinic/Group Practice 9830002534 Receives reassigned benefits from 9 practitioners
Practice locations: Naugatuck, CT; Simsbury, CT; Stamford, CT; Trumbull, CT; Vernon, CT; Vernon Rockville, CT; Wallingford, CT; West Hartford, CT…

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

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1124841600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1564963200000",
    "number": "1164415196",
    "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": "1 EMERSON DR",
            "address_2": "KIMBERLY HALL NORTH",
            "city": "WINDSOR",
            "state": "CT",
            "postal_code": "06095",
            "telephone_number": "860-688-6443",
            "fax_number": "860-688-5230"
        }
    ],
    "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, AREA CONTROLLER",
        "authorized_official_telephone_number": "410-832-7790"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207RG0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Geriatric Medicine",
            "state": "CT",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004195021",
            "state": "CT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004126919",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Windsor, CT

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.