Provider Demographics
NPI:1184626590
Name:GENETOS, BASIL C (MD)
Entity type:Individual
Prefix:
First Name:BASIL
Middle Name:C
Last Name:GENETOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3926 NEW VISION DR
Mailing Address - Street 2:SUITE3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-373-7875
Mailing Address - Fax:260-373-9705
Practice Address - Street 1:11108 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1730
Practice Address - Country:US
Practice Address - Phone:260-266-5700
Practice Address - Fax:260-266-5920
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2016-11-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01024857A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100186010Medicaid
IN060070579OtherRR MEDICARE
IN000000641079OtherANTHEM
OH0528012Medicaid
IND94468Medicare UPIN
IN100186010Medicaid
IN193590FMedicare PIN
IN193580FMedicare PIN
IN264380BBMedicare PIN