Basic Information
| Provider Information | |||||||||
| NPI: | 1801814611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENNARO | ||||||||
| FirstName: | VICTOR | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 706 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032640706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034818757 | ||||||||
| FaxNumber: | 6032382163 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 BOULDER POINT DRIVE | ||||||||
| Address2: | PLYMOUTH ORTHOPEDICS AND SPORTS MEDICINE CLINIC | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032643428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035361565 | ||||||||
| FaxNumber: | 6035361200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 11/06/2015 | ||||||||
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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 | 207X00000X | 8934 | NH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3164921 | 01 | NH | CIGNA | OTHER | Z51935 | 01 | MA | ANTHEM | OTHER | 18P031 | 01 | NH | MVP | OTHER | 0400634Y0NH02 | 01 | NH | ANTHEM | OTHER | 158488245 | 01 | NH | TRICARE | OTHER | 3070671 | 05 | NH | MEDICAID | 0019104 | 01 | VT | ANTHEM | OTHER | 175805800 | 01 | NH | US DEPARTMENT OF LABOR | OTHER | 200043876 | 01 | NH | RAILROAD MEDICARE | OTHER | 30005795 | 05 | NH | MEDICAID | 4483620001 | 01 | NH | DMERC | OTHER | ORE2681 | 05 | VT | MEDICAID | 5330990 | 01 | NH | CCN | OTHER |