Provider Demographics
NPI:1861856262
Name:MARK GENNARO MD PC
Entity Type:Organization
Organization Name:MARK GENNARO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BETZ
Authorized Official - Suffix:
Authorized Official - Credentials:BS,RVT
Authorized Official - Phone:631-385-7258
Mailing Address - Street 1:270 PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-1605
Mailing Address - Country:US
Mailing Address - Phone:631-385-7258
Mailing Address - Fax:
Practice Address - Street 1:270 PULASKI RD
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1605
Practice Address - Country:US
Practice Address - Phone:631-385-7258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1831314343Medicare NSC