Provider Demographics
NPI:1215464094
Name:GENESIS GROUP OF FAMILY PRACTICES LLC
Entity type:Organization
Organization Name:GENESIS GROUP OF FAMILY PRACTICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHANMUGAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-218-2353
Mailing Address - Street 1:1133 SAXON BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8425
Mailing Address - Country:US
Mailing Address - Phone:386-218-2353
Mailing Address - Fax:
Practice Address - Street 1:800 S NOVA RD
Practice Address - Street 2:STE J
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9048
Practice Address - Country:US
Practice Address - Phone:386-218-2353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8600208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty