MEDICARE: GEN LABORATORIES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207SC0300X	Clinical Cytogenetics Physician	33D0169767 PFI 3356	NY

General Provider Information

NPI Number	:	1467451872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEN LABORATORIES LLC

Provider Business Mailing Address
First Line	:	490 DELAWARE AVENUE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14202-1304
Country	:	US
Telephone Number	:	716-881-4865
Fax Number	:	716-881-5081

Provider Business Practice Location Address
First Line	:	490 DELAWARE AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14202-1304
Country	:	US
Telephone Number	:	716-881-4865
Fax Number	:	716-881-5081

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MARK KOVINSKY
Credential	:
Telephone Number	:	484-494-3121

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	04/09/2014

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