Provider Demographics
NPI:1245803402
Name:GENESIS MEDICAL DIAGNOSTICS PLLC
Entity Type:Organization
Organization Name:GENESIS MEDICAL DIAGNOSTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:EWAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:281-415-6687
Mailing Address - Street 1:14090 FM 2920 RD STE 345G
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77377-5549
Mailing Address - Country:US
Mailing Address - Phone:281-415-6687
Mailing Address - Fax:
Practice Address - Street 1:4195 NACO PERRIN BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-2505
Practice Address - Country:US
Practice Address - Phone:210-276-0045
Practice Address - Fax:832-565-1921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-23
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2216609OtherCLIA NUMBER