Basic Information
Provider Information | |||||||||
NPI: | 1114039286 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GENOVESE | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12510 PROSPERITY DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SILVER SPRING | ||||||||
State: | MD | ||||||||
PostalCode: | 209041663 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2404855200 | ||||||||
FaxNumber: | 3016256906 | ||||||||
Practice Location | |||||||||
Address1: | 10801 LOCKWOOD DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SILVER SPRING | ||||||||
State: | MD | ||||||||
PostalCode: | 209011556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3015932002 | ||||||||
FaxNumber: | 3015834781 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 07/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | D0035087 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | D0035087 | 01 | MD | STATE LICENSE | OTHER | M24743 | 01 | MD | CDS NUMBER | OTHER | AG2511144 | 01 | MD | DEA LICENSE NUMBER | OTHER | 209381200 | 05 | MD |   | MEDICAID |