Provider Demographics
NPI:1164549887
Name:GENECOV PLASTIC SURGERY GROUP, PA
Entity Type:Organization
Organization Name:GENECOV PLASTIC SURGERY GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULI
Authorized Official - Middle Name:
Authorized Official - Last Name:SMIDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-331-1900
Mailing Address - Street 1:7777 FOREST LN STE C528
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-6848
Mailing Address - Country:US
Mailing Address - Phone:972-331-1900
Mailing Address - Fax:972-331-1909
Practice Address - Street 1:7777 FOREST LN STE C528
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6848
Practice Address - Country:US
Practice Address - Phone:972-331-1900
Practice Address - Fax:972-331-1909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA2082S0099X
TX19138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112848004Medicaid
TXB102342OtherMEDICARE PTAN
TX112848004Medicaid