Healthcare Provider Details

I. General information

NPI: 1265439251
Provider Name (Legal Business Name): GLENN GENOVESE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 HOLLYBROOK DR STE 3400
LONGVIEW TX
75605-2412
US

IV. Provider business mailing address

PO BOX 50268
DENTON TX
76206-0268
US

V. Phone/Fax

Practice location:
  • Phone: 39-758-1464
  • Fax:
Mailing address:
  • Phone: 940-484-1500
  • Fax: 940-484-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberH7302
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberH7302
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: