MEDICARE: MARK HENRY GENICH M.D.

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	207Q00000X	Family Medicine Physician	MD00012957	WA

General Provider Information

NPI Number	:	1891718219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK HENRY GENICH M.D.

Provider Business Mailing Address
First Line	:	7105 GALLAGHER COVE RD NW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-9368
Country	:	US
Telephone Number	:	360-866-0844
Fax Number	:

Provider Business Practice Location Address
First Line	:	322 S BIRCH ST
Second Line	:
City	:	MCCLEARY
State	:	WA
Zip	:	98557-9522
Country	:	US
Telephone Number	:	360-495-3500
Fax Number	:	360-495-4423

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/09/2007

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