Basic Information
| Provider Information | |||||||||
| NPI: | 1366476525 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENNARO FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32 | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032160032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037356060 | ||||||||
| FaxNumber: | 6037356070 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 TOWN WEST RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032643428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035361200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GENNARO | ||||||||
| AuthorizedOfficialFirstName: | MARY-CATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6035361200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170100000X | 8933 | NH | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Medical Genetics, Ph.D. Medical Genetics |
ID Information
| ID | Type | State | Issuer | Description | 788360 | 01 | NH | MVP | OTHER | 30213803 | 05 | NH | MEDICAID |