=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205726585
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENERILLOMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2025
-----------------------------------------------------
Last Update Date | 07/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3129 KINGSLEY DR STE 1940
-----------------------------------------------------
City | PEARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77584-8511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-971-0809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1031 BOLIVAR POINT LN
-----------------------------------------------------
City | FRIENDSWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77546-7892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. MARLYN GENERILLO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 248-284-3359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------