Healthcare Provider Details

I. General information

NPI: 1477792034
Provider Name (Legal Business Name): RICHARD E GENOVESE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2009
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 CENTRAL ST
GARDNER MA
01440-1662
US

IV. Provider business mailing address

52 CENTRAL ST
GARDNER MA
01440-1662
US

V. Phone/Fax

Practice location:
  • Phone: 978-632-5722
  • Fax:
Mailing address:
  • Phone: 978-632-5722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number001625
License Number StateMA

VIII. Authorized Official

Name: RICHARD E GENOVESE
Title or Position: OWNER
Credential:
Phone: 978-632-5722