Provider Demographics
NPI: | 1376089698 |
---|---|
Name: | GENNEURO, PLLC |
Entity Type: | Organization |
Organization Name: | GENNEURO, PLLC |
Other - Org Name: | GENESIS NEUROSCIENCE CLINIC |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MONICA |
Authorized Official - Middle Name: | K |
Authorized Official - Last Name: | CRANE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 865-888-9494 |
Mailing Address - Street 1: | 1400 DOWELL SPRINGS BLVD STE 340 |
Mailing Address - Street 2: | |
Mailing Address - City: | KNOXVILLE |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37909-2445 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 865-888-9494 |
Mailing Address - Fax: | 865-444-7672 |
Practice Address - Street 1: | 1400 DOWELL SPRINGS BLVD |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | KNOXVILLE |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37909-2456 |
Practice Address - Country: | US |
Practice Address - Phone: | 865-888-9494 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-01-10 |
Last Update Date: | 2019-03-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207QG0300X | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | Group - Multi-Specialty |