MEDICARE: GENESIS PHYSICIAN ALLIANCE, INC

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1891163366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS PHYSICIAN ALLIANCE, INC

Provider Business Mailing Address
First Line	:	2717 COMMERCIAL CENTER BLVD STE E200
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-6410
Country	:	US
Telephone Number	:	832-712-5904
Fax Number	:	832-913-1173

Provider Business Practice Location Address
First Line	:	2717 COMMERCIAL CENTER BLVD STE E200
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-6410
Country	:	US
Telephone Number	:	832-712-5904
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	FRAN MCSHAN
Credential	:
Telephone Number	:	832-913-5032

Provider Enumeration Date	:	09/14/2015
Last Update Date	:	07/19/2016

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