Provider Demographics
NPI:1740569763
Name:GENESIS PHYSICIAN ASSOCIATES LLC
Entity Type:Organization
Organization Name:GENESIS PHYSICIAN ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:UCHE
Authorized Official - Middle Name:
Authorized Official - Last Name:OBISIKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-436-2671
Mailing Address - Street 1:4801 N BUTLER AVENUE
Mailing Address - Street 2:SUITE 8102
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-0818
Mailing Address - Country:US
Mailing Address - Phone:505-436-2671
Mailing Address - Fax:
Practice Address - Street 1:4801 N BUTLER AVENUE
Practice Address - Street 2:SUITE 8102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-0818
Practice Address - Country:US
Practice Address - Phone:505-436-2671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-08
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0141207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty