1417021247 NPI number — GENECOV PLASTIC SURGERY GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417021247 NPI number — GENECOV PLASTIC SURGERY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENECOV PLASTIC SURGERY GROUP
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:
1417021247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7777 FOREST LN
Provider Second Line Business Mailing Address:
SUITE C717
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75230-2505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-566-6555
Provider Business Mailing Address Fax Number:
972-566-6017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 FOREST LN
Provider Second Line Business Practice Location Address:
SUITE B312
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75230-2505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-566-6555
Provider Business Practice Location Address Fax Number:
972-566-6017
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GENECOV
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
972-566-6555

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  NA , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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