Provider Demographics
NPI:1669425682
Name:GENESIS EMERGENCY MEDICINE SERVICES LLC
Entity type:Organization
Organization Name:GENESIS EMERGENCY MEDICINE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:K
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-524-3018
Mailing Address - Street 1:PO BOX 11527
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-1527
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:386-274-7801
Practice Address - Street 1:1200 W LIBERTY RD
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-1621
Practice Address - Country:US
Practice Address - Phone:580-889-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159042002Medicaid
AR5F445OtherBLUE CROSS BLUE SHIELD
ARDE3171OtherRAILROAD MEDICARE
ARDE3171OtherRAILROAD MEDICARE