Healthcare Provider Details

I. General information

NPI: 1134625924
Provider Name (Legal Business Name): ABIGAIL GENCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 BURNET AVE
CINCINNATI OH
45229-2833
US

IV. Provider business mailing address

4616 LARGO DR
CINCINNATI OH
45236-3212
US

V. Phone/Fax

Practice location:
  • Phone: 614-325-2214
  • Fax:
Mailing address:
  • Phone: 614-325-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.072651
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number35141895
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: