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General NPI Number Information
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NPI Number | 1437418886
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Entity Type | Individual
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Provider Name | BRADLEY MARCUS GENOVESE M.D
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Gender | Male
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Dates
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Enumeration Date | 05/04/2012
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Last Update Date | 02/28/2022
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Provider Practice Location Address
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Address Line | 30432 PASEO DEL VALLE
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City | LAGUNA NIGUEL
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State | CA
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Zip | 92677-2313
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Country | US
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Telephone | 949-683-3072
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 35100
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City | BILLINGS
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State | MT
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Zip | 59107-5100
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Country | US
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Telephone | 406-238-2500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 94365
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License Number State | MT
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