Provider Demographics
NPI:1962483446
Name:GENNOSA, THOMAS JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:GENNOSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROBERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27871-9567
Mailing Address - Country:US
Mailing Address - Phone:252-795-5555
Mailing Address - Fax:252-795-5566
Practice Address - Street 1:504 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROBERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27871-9567
Practice Address - Country:US
Practice Address - Phone:252-795-5555
Practice Address - Fax:252-795-5566
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912294Medicaid
NC2278733BMedicare PIN
G65459Medicare UPIN