Provider Demographics
NPI:1427145184
Name:POLVERINO, GENNARO MARC (MD)
Entity type:Individual
Prefix:
First Name:GENNARO
Middle Name:MARC
Last Name:POLVERINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-368-3531
Mailing Address - Fax:585-368-3747
Practice Address - Street 1:30 HAGEN DR STE 300
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2658
Practice Address - Country:US
Practice Address - Phone:585-922-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272834207P00000X, 207Q00000X, 207P00000X
CO46165207Q00000X
WY7802A207Q00000X
NY60 272834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03941513Medicaid
NYJ400160564/GRP70008AMedicare PIN
NYJ400160563/GRPBA0017Medicare PIN