Basic Information
| Provider Information | |||||||||
| NPI: | 1750377941 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENOVA | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5551 WINGHAVEN BLVD | ||||||||
| Address2: | SUITE 132 | ||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633683617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366952520 | ||||||||
| FaxNumber: | 6366952526 | ||||||||
| Practice Location | |||||||||
| Address1: | 5551 WINGHAVEN BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633683630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366857724 | ||||||||
| FaxNumber: | 3145905914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MDR3C40 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110229354 | 01 | MO | RR MEDICARE | OTHER | P00254751 | 01 | MO | RR MEDICARE | OTHER |