Healthcare Provider Details

I. General information

NPI: 1124318209
Provider Name (Legal Business Name): DR. RENEE GENOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 HARDEN BLVD
LAKELAND FL
33803-7952
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD MANAGED CARE DEPT
LAKELAND FL
33805
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1250
  • Fax: 863-687-1258
Mailing address:
  • Phone: 863-687-1100
  • Fax: 863-630-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberME143995
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: