Provider Demographics
NPI:1477792034
Name:RICHARD E GENOVESE
Entity Type:Organization
Organization Name:RICHARD E GENOVESE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:GENOVESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-632-5722
Mailing Address - Street 1:52 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1662
Mailing Address - Country:US
Mailing Address - Phone:978-632-5722
Mailing Address - Fax:
Practice Address - Street 1:52 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1662
Practice Address - Country:US
Practice Address - Phone:978-632-5722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA001625213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1304830001Medicare NSC