Provider Demographics
NPI:1992301741
Name:GENESIS HEALTH FITNESS PLLC
Entity type:Organization
Organization Name:GENESIS HEALTH FITNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:OLADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-263-7490
Mailing Address - Street 1:12155 SHADOW CREEK PKWY STE 114
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7289
Mailing Address - Country:US
Mailing Address - Phone:832-263-7490
Mailing Address - Fax:888-977-1299
Practice Address - Street 1:12155 SHADOW CREEK PKWY STE 114
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7289
Practice Address - Country:US
Practice Address - Phone:832-263-7490
Practice Address - Fax:888-977-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-08
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency CareGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
05853676OtherECFMG