Provider Demographics
NPI:1548302763
Name:GENESIS II, INC.
Entity type:Organization
Organization Name:GENESIS II, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-978-5191
Mailing Address - Street 1:1239 SPRING GARDEN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-3206
Mailing Address - Country:US
Mailing Address - Phone:215-978-5191
Mailing Address - Fax:215-978-8017
Practice Address - Street 1:1239 SPRING GARDEN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-3206
Practice Address - Country:US
Practice Address - Phone:215-978-5191
Practice Address - Fax:215-978-8017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA807289251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1008220780001Medicaid