Provider Demographics
NPI:1619019239
Name:GENRAICH, MELVYN H (MD)
Entity Type:Individual
Prefix:
First Name:MELVYN
Middle Name:H
Last Name:GENRAICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 S MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-1026
Mailing Address - Country:US
Mailing Address - Phone:806-266-5565
Mailing Address - Fax:806-266-5342
Practice Address - Street 1:201 E GRANT AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:TX
Practice Address - Zip Code:79346-3444
Practice Address - Country:US
Practice Address - Phone:806-266-5565
Practice Address - Fax:806-266-5342
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6784207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B22926Medicare UPIN