MEDICARE: GENICE MARK MPT

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1780283994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENICE MARK MPT

Provider Business Mailing Address
First Line	:	62 HAWTHORNE ST N
Second Line	:
City	:	GREENWICH
State	:	CT
Zip	:	06831-4202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	388 WESTCHESTER AVE STE 1A
Second Line	:
City	:	PORT CHESTER
State	:	NY
Zip	:	10573-3623
Country	:	US
Telephone Number	:	914-939-6400
Fax Number	:

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

Provider Enumeration Date	:	10/19/2020
Last Update Date	:	10/19/2020

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