Basic Information
| Provider Information | |||||||||
| NPI: | 1396889960 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR. GENOVA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 S WOODS MILL RD | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3666857804 | ||||||||
| FaxNumber: | 3145762433 | ||||||||
| Practice Location | |||||||||
| Address1: | 5551 WINGHAVEN BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633683630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366952520 | ||||||||
| FaxNumber: | 3145905925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | SNIDER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP PHYSICIAN NETWORK | ||||||||
| AuthorizedOfficialTelephone: | 6366857804 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKE'S MEDICAL GROUP | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | DD8375 | 01 | MO | RR MEDICARE | OTHER |