Provider Demographics
NPI:1801830179
Name:GENOVESE ELLIOTT, THERESA MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MICHELLE
Last Name:GENOVESE ELLIOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:MICHELLE
Other - Last Name:GENOVESE ELLIOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:4801 BECKNER RD LEVEL 1 POD 2
Practice Address - Street 2:STE 1650
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-0000
Practice Address - Country:US
Practice Address - Phone:505-772-2000
Practice Address - Fax:505-983-5202
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM992062081P2900X
NM99-2062081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG75043Medicare UPIN
NM344412801Medicare ID - Type Unspecified