Healthcare Provider Details

I. General information

NPI: 1144599440
Provider Name (Legal Business Name): GENESISCARE USA OF FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4030 SHERIDAN ST SUITE C
HOLLYWOOD FL
33021-3564
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 954-961-7500
  • Fax: 954-964-8965
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: IAN WONG
Title or Position: CFO
Credential:
Phone: 303-249-7486