Healthcare Provider Details

I. General information

NPI: 1053200543
Provider Name (Legal Business Name): GENEVIVE ACO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 BROADWAY ST NE STE 300
MINNEAPOLIS MN
55413-1761
US

IV. Provider business mailing address

3433 BROADWAY ST NE STE 300
MINNEAPOLIS MN
55413-1761
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-7737
  • Fax: 651-383-4551
Mailing address:
  • Phone: 763-587-7737
  • Fax: 651-383-4551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER WELSH
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 763-587-7737