MEDICARE: MAX JORDAN GENECOV

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1528792538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAX JORDAN GENECOV

Provider Business Mailing Address
First Line	:	223 W 38TH ST UNIT 493
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10018-5644
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	223 W 38TH ST UNIT 493
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10018-5644
Country	:	US
Telephone Number	:	917-924-2621
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2022
Last Update Date	:	07/14/2022

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