NPIMap

Organization Active NPI

Genesis Medical Group, LLC.

  • Prosthetic/Orthotic Supplier
  • Lake Oswego, OR
National Provider Identifier
1457517138
Registry record updated Apr 3, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Prosthetic/Orthotic SupplierTaxonomy code 335E00000X
License
1355445-0 Issued in OR
Legal business name
GENESIS MEDICAL GROUP, LLC.
Practice address
16679 Boones Ferry Rd Ste 215
Lake Oswego, OR 97035-4368
Phone
(503) 699-1911
Fax
(503) 699-1912
NPI assigned
Aug 1, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 3, 2012

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

Authorized official

Name
Mr. Wyatt James Brown, CPED
Title
Director of Operation
Phone
(503) 699-1911

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Prosthetic/Orthotic Supplier 335E00000X 1355445-0 OR Primary

Addresses

Primary practice location

16679 Boones Ferry Rd Ste 215
Lake Oswego, OR 97035-4368

Mailing address

16679 Boones Ferry Rd Ste 215
Lake Oswego, OR 97035-4368
Phone (503) 699-1911

Other identifiers 2

IdentifierTypeStateIssuer
500608071MedicaidOR
081911000OtherORBLUE CROSS BLUE SHIELD

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

Subparts reporting this organization as parent 2

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

NPI Registry JSON

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

{
    "created_epoch": "1217548800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1333411200000",
    "number": "1457517138",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16679 BOONES FERRY RD STE 215",
            "city": "LAKE OSWEGO",
            "state": "OR",
            "postal_code": "970354368",
            "telephone_number": "503-699-1911",
            "fax_number": "503-699-1912"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16679 BOONES FERRY RD STE 215",
            "city": "LAKE OSWEGO",
            "state": "OR",
            "postal_code": "970354368",
            "telephone_number": "503-699-1911",
            "fax_number": "503-699-1912"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GENESIS MEDICAL GROUP, LLC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-01",
        "last_updated": "2012-04-03",
        "status": "A",
        "authorized_official_last_name": "BROWN",
        "authorized_official_first_name": "WYATT",
        "authorized_official_middle_name": "JAMES",
        "authorized_official_title_or_position": "DIRECTOR OF OPERATION",
        "authorized_official_telephone_number": "503-699-1911",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CPED"
    },
    "taxonomies": [
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": "OR",
            "license": "1355445-0",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500608071",
            "state": "OR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "081911000",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Oswego, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 3, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.