Provider Demographics
NPI:1902009822
Name:GENIG, MARTHA ELLEN
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ELLEN
Last Name:GENIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7804 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1702
Mailing Address - Country:US
Mailing Address - Phone:313-388-0033
Mailing Address - Fax:313-388-1188
Practice Address - Street 1:7804 ALLEN RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1702
Practice Address - Country:US
Practice Address - Phone:313-388-0033
Practice Address - Fax:313-388-1188
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704111736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine