Provider Demographics
NPI:1013914746
Name:GENNAULA, CHARLES PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:PATRICK
Last Name:GENNAULA
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 1:315 STETTLER DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:15025-3164
Mailing Address - Country:US
Mailing Address - Phone:412-287-0699
Mailing Address - Fax:724-929-3229
Practice Address - Street 1:100 PEASANT VILLAGE LN
Practice Address - Street 2:SUITE 100
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-4333
Practice Address - Country:US
Practice Address - Phone:724-929-7800
Practice Address - Fax:724-929-3229
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050096L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018903290004Medicaid
PA0015218170004Medicaid
PA0018903290001Medicaid
PA0015218170004Medicaid
PA0018903290004Medicaid