Healthcare Provider Details

I. General information

NPI: 1891718219
Provider Name (Legal Business Name): MARK HENRY GENICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 S BIRCH ST
MCCLEARY WA
98557-9522
US

IV. Provider business mailing address

7105 GALLAGHER COVE RD NW
OLYMPIA WA
98502-9368
US

V. Phone/Fax

Practice location:
  • Phone: 360-495-3500
  • Fax: 360-495-4423
Mailing address:
  • Phone: 360-866-0844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00012957
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: