Provider Demographics
NPI:1821104308
Name:GENACK, SHELDON H (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELDON
Middle Name:H
Last Name:GENACK
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 1:1728 BROADWAY
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1630
Mailing Address - Country:US
Mailing Address - Phone:516-887-5788
Mailing Address - Fax:516-887-5990
Practice Address - Street 1:1728 BROADWAY
Practice Address - Street 2:SUITE 5
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1630
Practice Address - Country:US
Practice Address - Phone:516-887-5788
Practice Address - Fax:516-887-5990
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198502174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY377191Medicare ID - Type Unspecified
NYG10288Medicare UPIN