Healthcare Provider Details

I. General information

NPI: 1992173603
Provider Name (Legal Business Name): GENESISCARE USA OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9325 GLADES RD SUITE 101
BOCA RATON FL
33434-3988
US

IV. Provider business mailing address

2270 COLONIAL BLVD
FORT MYERS FL
33907-1412
US

V. Phone/Fax

Practice location:
  • Phone: 561-482-8887
  • Fax: 561-451-1768
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHADEN MARZOUK
Title or Position: PRESIDENT
Credential:
Phone: 239-931-7254