Healthcare Provider Details

I. General information

NPI: 1427677038
Provider Name (Legal Business Name): GENESISCARE USA OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36468 EMERALD COAST PKWY STE 11103
DESTIN FL
32541-0741
US

IV. Provider business mailing address

1419 SE 8TH TER STE 200
CAPE CORAL FL
33990-3213
US

V. Phone/Fax

Practice location:
  • Phone: 850-660-5204
  • Fax: 850-660-5206
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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