Provider Demographics
NPI:1366450603
Name:GENEVA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:GENEVA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:COSPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-684-9208
Mailing Address - Street 1:701 W MAPLE AVE
Mailing Address - Street 2:PO BOX 328
Mailing Address - City:GENEVA
Mailing Address - State:AL
Mailing Address - Zip Code:36340-1609
Mailing Address - Country:US
Mailing Address - Phone:334-684-9208
Mailing Address - Fax:334-684-1302
Practice Address - Street 1:701 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:AL
Practice Address - Zip Code:36340-1609
Practice Address - Country:US
Practice Address - Phone:334-684-9208
Practice Address - Fax:334-684-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00019314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI390Medicare PIN