Provider Demographics
NPI:1366050007
Name:GENERATION CLINICAL PARTNERS LLC
Entity type:Organization
Organization Name:GENERATION CLINICAL PARTNERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-925-0903
Mailing Address - Street 1:PO BOX 14713
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4042
Mailing Address - Country:US
Mailing Address - Phone:314-925-0903
Mailing Address - Fax:314-764-2279
Practice Address - Street 1:1251 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6735
Practice Address - Country:US
Practice Address - Phone:314-925-0903
Practice Address - Fax:314-764-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty