Organization
GENESIS MEDICAL GROUP, LLC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. WYATT JAMES BROWN CPED (DIRECTOR OF OPERATION)
(503) 699-1911
Entity
Organization
Contact information
Practice address
16679 BOONES FERRY RD STE 215, LAKE OSWEGO, OR 97035-4368
(503) 699-1911
(503) 699-1912
Mailing address
16679 BOONES FERRY RD STE 215, LAKE OSWEGO, OR 97035-4368
(503) 699-1911
(503) 699-1912
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
1355445-0
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
081911000
BLUE CROSS BLUE SHIELD
OR
05
—
500608071
—
OR
Enumeration date
08/01/2008
Last updated
04/03/2012
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