Healthcare Provider Details

I. General information

NPI: 1447525431
Provider Name (Legal Business Name): GENESIS PHYSICIANS GROUP,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29777 TELEGRAPH RD SUITE 2415
SOUTHFIELD MI
48034-1303
US

IV. Provider business mailing address

PO BOX 2477
BIRMINGHAM MI
48012-2477
US

V. Phone/Fax

Practice location:
  • Phone: 248-419-2416
  • Fax: 248-419-2374
Mailing address:
  • Phone: 248-270-7246
  • Fax: 866-380-2182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALLIE GALOVICH
Title or Position: BILLER
Credential: CPC
Phone: 248-593-9780