Provider Demographics
NPI:1043294846
Name:GENNAOUI, JAD M (MD)
Entity Type:Individual
Prefix:
First Name:JAD
Middle Name:M
Last Name:GENNAOUI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 954129
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-4129
Mailing Address - Country:US
Mailing Address - Phone:314-821-8055
Mailing Address - Fax:314-821-1833
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-4492
Practice Address - Fax:314-525-4481
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR93302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1600258OtherUHC
112315OtherHEALTHLINK
1600258OtherUHC