MEDICARE: CHARLES P. GENNAULA, M.D., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician

General Provider Information

NPI Number	:	1073170569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLES P. GENNAULA, M.D., P.C.

Provider Business Mailing Address
First Line	:	100 PEASANT VILLAGE LN STE 100
Second Line	:
City	:	ROSTRAVER TOWNSHIP
State	:	PA
Zip	:	15012-4333
Country	:	US
Telephone Number	:	724-929-7800
Fax Number	:	724-929-7800

Provider Business Practice Location Address
First Line	:	100 PEASANT VILLAGE LN STE 100
Second Line	:
City	:	ROSTRAVER TOWNSHIP
State	:	PA
Zip	:	15012-4333
Country	:	US
Telephone Number	:	724-929-7800
Fax Number	:	724-929-7800

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MR. NIKKI COSTELLO
Credential	:
Telephone Number	:	724-929-7800

Provider Enumeration Date	:	05/21/2019
Last Update Date	:	05/21/2019

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