Healthcare Provider Details

I. General information

NPI: 1073612339
Provider Name (Legal Business Name): GENTA MEDICAL CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 1ST AVE SW
JACKSONVILLE AL
36265-3329
US

IV. Provider business mailing address

1460 1ST AVE SW
JACKSONVILLE AL
36265-3329
US

V. Phone/Fax

Practice location:
  • Phone: 256-435-2895
  • Fax: 256-435-2969
Mailing address:
  • Phone: 256-435-2895
  • Fax: 256-435-2969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number15032
License Number StateAL

VIII. Authorized Official

Name: DR. JOHN OSCAR BROWN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 256-435-2895