MEDICARE: GENOMIC HEALTH INC.

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	291U00000X	Clinical Medical Laboratory	03D2048606	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275913642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENOMIC HEALTH INC.

Provider Business Mailing Address
First Line	:	PO BOX 742415
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90074-2415
Country	:	US
Telephone Number	:	866-662-6897
Fax Number	:	866-383-1932

Provider Business Practice Location Address
First Line	:	445 N 5TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-2157
Country	:	US
Telephone Number	:	844-539-3309
Fax Number	:	602-343-8440

Authorized Official
Title or Position	:	TREASURER
Name	:	KYLE STACEY
Credential	:
Telephone Number	:	608-284-5700

Provider Enumeration Date	:	06/01/2015
Last Update Date	:	04/11/2023

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