Provider Demographics
NPI:1609177864
Name:CHARLES R GENOVESE JR MD INC
Entity type:Organization
Organization Name:CHARLES R GENOVESE JR MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GENOVESE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:985-878-4183
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:70443-0969
Mailing Address - Country:US
Mailing Address - Phone:985-878-4183
Mailing Address - Fax:985-878-3830
Practice Address - Street 1:312 E RAIL ROAD AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443
Practice Address - Country:US
Practice Address - Phone:985-878-4183
Practice Address - Fax:985-878-3830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015669174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty