Basic Information
| Provider Information | |||||||||
| NPI: | 1972618890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENCK | ||||||||
| FirstName: | ROD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15223 N 87TH ST | ||||||||
| Address2: | #110 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852602639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806824100 | ||||||||
| FaxNumber: | 4806824101 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 E DEUCE OF CLUBS | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859014829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806824118 | ||||||||
| FaxNumber: | 4806824101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 03/31/2016 | ||||||||
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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 | 207Q00000X | 1963 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 442294 | 05 | AZ | MEDICAID |