Provider Demographics
NPI:1053664938
Name:GENESIS MEDICAL CENTER, ALEDO
Entity type:Organization
Organization Name:GENESIS MEDICAL CENTER, ALEDO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:MALAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-421-6508
Mailing Address - Street 1:1007 NW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-1317
Mailing Address - Country:US
Mailing Address - Phone:309-582-3701
Mailing Address - Fax:309-582-3737
Practice Address - Street 1:1007 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-1317
Practice Address - Country:US
Practice Address - Phone:309-582-3701
Practice Address - Fax:309-582-3737
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESIS HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-17
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07400036OtherILLINOIS HEALTH CONNECT PRIMARY CARE PROVIDER ID NUMBER
IL=========002Medicaid
IL=========002Medicaid
IL143453Medicare Oscar/Certification