Provider Demographics
NPI:1003175563
Name:GENESEE VASCULAR LABORATORY, INC.
Entity Type:Organization
Organization Name:GENESEE VASCULAR LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:PENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-454-6610
Mailing Address - Street 1:919 WESTFALL RD STE B100
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2628
Mailing Address - Country:US
Mailing Address - Phone:585-454-6610
Mailing Address - Fax:
Practice Address - Street 1:2060 FAIRPORT NINE MILE POINT RD
Practice Address - Street 2:SUITE 400
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1749
Practice Address - Country:US
Practice Address - Phone:585-454-6610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-03
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03158289Medicaid