Provider Demographics
NPI:1124008677
Name:GENESISCARE USA OF KENTUCKY LLC
Entity Type:Organization
Organization Name:GENESISCARE USA OF KENTUCKY LLC
Other - Org Name:BLUEGRASS RADIATION ONCOLOGY CENTER
Other - Org Type:Doing Business As
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 1:2 PHYSICIANS PARK
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4203
Practice Address - Country:US
Practice Address - Phone:502-223-3551
Practice Address - Fax:502-223-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65940058Medicaid
KY65940058Medicaid
7865Medicare PIN