Provider Demographics
NPI:1891718219
Name:GENICH, MARK HENRY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HENRY
Last Name:GENICH
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 1:7105 GALLAGHER COVE RD NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9368
Mailing Address - Country:US
Mailing Address - Phone:360-866-0844
Mailing Address - Fax:
Practice Address - Street 1:322 S BIRCH ST
Practice Address - Street 2:
Practice Address - City:MCCLEARY
Practice Address - State:WA
Practice Address - Zip Code:98557-9522
Practice Address - Country:US
Practice Address - Phone:360-495-3500
Practice Address - Fax:360-495-4423
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAD08035Medicare UPIN