Provider Demographics
NPI:1750647780
Name:GENESIS INTERNATIONAL MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:GENESIS INTERNATIONAL MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:C
Authorized Official - Last Name:NEWTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-389-7682
Mailing Address - Street 1:7529 TALL TREE CT
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-5849
Mailing Address - Country:US
Mailing Address - Phone:407-468-3075
Mailing Address - Fax:
Practice Address - Street 1:323 W OAK ST
Practice Address - Street 2:SUITE A
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4421
Practice Address - Country:US
Practice Address - Phone:407-468-3075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME508202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty