Provider Demographics
NPI:1427339399
Name:GENESISCARE USA OF FLORIDA LLC
Entity type:Organization
Organization Name:GENESISCARE USA OF FLORIDA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-931-7275
Mailing Address - Street 1:2160 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:914 MAR WALT DR
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6706
Practice Address - Country:US
Practice Address - Phone:850-226-6572
Practice Address - Fax:850-862-8564
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESISCARE USA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-06
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77215CMedicare PIN