Healthcare Provider Details

I. General information

NPI: 1013937598
Provider Name (Legal Business Name): GENECOV PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN SUITE B326
DALLAS TX
75230-2505
US

IV. Provider business mailing address

7777 FOREST LN SUITE B326
DALLAS TX
75230-2505
US

V. Phone/Fax

Practice location:
  • Phone: 972-566-8466
  • Fax: 972-566-8329
Mailing address:
  • Phone: 972-566-8466
  • Fax: 972-566-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA W GENECOV
Title or Position: OWNER
Credential: MD
Phone: 972-566-8466