Provider Demographics
NPI:1093771297
Name:GENNUSO, ROSEMARIA (MD)
Entity Type:Individual
Prefix:
First Name:ROSEMARIA
Middle Name:
Last Name:GENNUSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8109 FREDERICKSBURG RD
Mailing Address - Street 2:PHYSICIAN PRACTICE SERVICES
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3311
Mailing Address - Country:US
Mailing Address - Phone:210-575-6240
Mailing Address - Fax:210-575-6280
Practice Address - Street 1:4410 MEDICAL DR
Practice Address - Street 2:STE 540
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6306
Practice Address - Country:US
Practice Address - Phone:210-575-6240
Practice Address - Fax:210-575-6280
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0411207T00000X, 208000000X, 2086S0102X, 2086X0206X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
8BX390OtherBCBS TX
TX178202105Medicaid
TX178202106OtherCSHCN
TX178202106OtherCSHCN
TX178202105Medicaid