Basic Information
| Provider Information | |||||||||
| NPI: | 1215984851 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | CARTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4841 MONROE ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194744064 | ||||||||
| FaxNumber: | 4194722772 | ||||||||
| Practice Location | |||||||||
| Address1: | 2142 N COVE BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192914438 | ||||||||
| FaxNumber: | 4194796078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35-080240 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2527091 | 05 | OH | MEDICAID | 000000393292 | 01 | ANTHEM | OTHER | 4908875 | 05 | MI | MEDICAID | 4908884 | 05 | MI | MEDICAID | P00361698 | 01 | TRICARE RR MEDICARE | OTHER |