Provider Demographics
NPI:1942208525
Name:GENEST, GLENN P (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:P
Last Name:GENEST
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 1:3455 MAIN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1147
Mailing Address - Country:US
Mailing Address - Phone:413-733-9600
Mailing Address - Fax:413-732-6534
Practice Address - Street 1:3455 MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1147
Practice Address - Country:US
Practice Address - Phone:413-733-9600
Practice Address - Fax:413-732-6534
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219834207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAGEJ27216OtherBLUE CROSS BLUE SHIELD
CT219834J597OtherCONNECTICARE
MA34234OtherHEALTH NEW ENGLAND
MA468903OtherTUFTS HEALTH PLANS
P00181345OtherRAILROAD MEDICARE
P00181345OtherRAILROAD MEDICARE
CT219834J597OtherCONNECTICARE