Provider Demographics
NPI:1154433746
Name:GENESIS RADIOLOGY, P.A.
Entity type:Organization
Organization Name:GENESIS RADIOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TESORIERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-599-1860
Mailing Address - Street 1:PO BOX 864768
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75086-4768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2828 W PARKER RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-9153
Practice Address - Country:US
Practice Address - Phone:972-599-1860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG70112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180974600OtherDEPT OF LABOR
TX113724202Medicaid
TX8J8280OtherBCBS
LA1593231Medicaid
00520VMedicare PIN
TX180974600OtherDEPT OF LABOR