Provider Demographics
NPI:1467451872
Name:GEN LABORATORIES LLC
Entity Type:Organization
Organization Name:GEN LABORATORIES LLC
Other - Org Name:GENETIC DIAGNOSTIC LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KOVINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-494-3121
Mailing Address - Street 1:490 DELAWARE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1304
Mailing Address - Country:US
Mailing Address - Phone:716-881-4865
Mailing Address - Fax:716-881-5081
Practice Address - Street 1:490 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1304
Practice Address - Country:US
Practice Address - Phone:716-881-4865
Practice Address - Fax:716-881-5081
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KOVO CAPITAL VENTURES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-18
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33D0169767 PFI 3356207SC0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical CytogeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
008821Medicare ID - Type Unspecified