1487632998 NPI number — GENEDX LLC

Table of content: ALEXIS WAKEHAM PTA (NPI 1740928530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487632998 NPI number — GENEDX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENEDX LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487632998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 LUDLOW ST, NORTH TOWER, FL 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAMFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06902-6991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-519-2100
Provider Business Mailing Address Fax Number:
201-421-2010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 & 207 PERRY PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAITHERSBURG
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20877-2142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-519-2100
Provider Business Practice Location Address Fax Number:
201-421-2010
Provider Enumeration Date:
01/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FEELEY
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
301-519-2100

Provider Taxonomy Codes

  • Taxonomy code: 170100000X , with the licence number:  870020 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 953 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21D0969951 . This is a "CMS CLIA CERTIFICATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 953 . This is a "MARYLAND STATE LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 012979000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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