Healthcare Provider Details

I. General information

NPI: 1366450603
Provider Name (Legal Business Name): GENEVA MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W MAPLE AVE
GENEVA AL
36340-1609
US

IV. Provider business mailing address

701 W MAPLE AVE PO BOX 328
GENEVA AL
36340-1609
US

V. Phone/Fax

Practice location:
  • Phone: 334-684-9208
  • Fax: 334-684-1302
Mailing address:
  • Phone: 334-684-9208
  • Fax: 334-684-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00019314
License Number StateAL

VIII. Authorized Official

Name: DR. CHRISTOPHER S. COSPER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 334-684-9208