Provider Demographics
NPI:1972618890
Name:GENCK, ROD E (PA)
Entity Type:Individual
Prefix:
First Name:ROD
Middle Name:E
Last Name:GENCK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:15223 N 87TH ST
Mailing Address - Street 2:#110
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2639
Mailing Address - Country:US
Mailing Address - Phone:480-682-4100
Mailing Address - Fax:480-682-4101
Practice Address - Street 1:680 E DEUCE OF CLUBS
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-4829
Practice Address - Country:US
Practice Address - Phone:480-682-4118
Practice Address - Fax:480-682-4101
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ1963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ442294Medicaid
AZS36300Medicare UPIN
AZZ103761Medicare PIN
AZ442294Medicaid