Basic Information
| Provider Information | |||||||||
| NPI: | 1336642545 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESISCARE USA OF FLORIDA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLACKWELL BREAST SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2270 COLONIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 7451 GLADIOLUS DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339085193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317212 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2018 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2399317275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENESISCARE USA INC. | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.