MEDICARE: GENPROV 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	207R00000X	Internal Medicine Physician	Q2173	TX
2	207P00000X	Emergency Medicine Physician	Q2173	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Q2173	OTHER	TX	TEXAS MEDICAL BOARD

General Provider Information

NPI Number	:	1487141032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENPROV LLC

Provider Business Mailing Address
First Line	:	2301 HARBOR CHASE DR
Second Line	:
City	:	PEARLAND
State	:	TX
Zip	:	77584-3423
Country	:	US
Telephone Number	:	404-441-8752
Fax Number	:

Provider Business Practice Location Address
First Line	:	2301 HARBOR CHASE DRIVE
Second Line	:
City	:	PEARLAND
State	:	TX
Zip	:	77584
Country	:	US
Telephone Number	:	404-441-8752
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROGER OLADE
Credential	:	MD
Telephone Number	:	404-441-8752

Provider Enumeration Date	:	04/19/2018
Last Update Date	:	04/19/2018

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Directions to “GENPROV LLC ” Practice Location

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