Provider Demographics
NPI:1780957696
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:SHADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARZOUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-931-7254
Mailing Address - Street 1:1419 SE 8TH TER STE 200
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3213
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:200 3RD AVE W
Practice Address - Street 2:SUITE 210
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8626
Practice Address - Country:US
Practice Address - Phone:941-792-0340
Practice Address - Fax:941-794-2251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESISCARE USA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-23
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77215KMedicare PIN