Healthcare Provider Details

I. General information

NPI: 1417489071
Provider Name (Legal Business Name): GENEVRA ADDIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 HAYES AVE
SANDUSKY OH
44870-3323
US

IV. Provider business mailing address

1111 HAYES AVE
SANDUSKY OH
44870-3323
US

V. Phone/Fax

Practice location:
  • Phone: 419-557-7076
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.139537
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.139537
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: