Provider Demographics
NPI:1891036810
Name:GENESISCARE USA OF FLORIDA LLC
Entity Type:Organization
Organization Name:GENESISCARE USA OF FLORIDA LLC
Other - Org Name:LAWRENCE R. BLACK, DO
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 1:13691 METRO PKWY STE 350
Practice Address - Street 2:METRO MEDICAL PLAZA
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4351
Practice Address - Country:US
Practice Address - Phone:239-768-5313
Practice Address - Fax:239-768-9559
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENESISCARE USA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-15
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCE7138OtherRAILROAD MEDICARE
FL77215FMedicare PIN