Genesiscare USA of Florida LLC

Primary specialty

Urology PhysicianTaxonomy code 208800000X

Legal business name

GENESISCARE USA OF FLORIDA LLC

Doing business as

Basil D Fossum MD

Practice address

914 Mar Walt Dr
Suite B
Fort Walton Beach, FL 32547-6706

Phone

(850) 226-6572

Fax

(850) 862-8564

NPI assigned

Sep 6, 2011

Last updated

Aug 24, 2020By the provider in NPPES

Organization subpart

Yes

Parent organization

GENESISCARE USA INC.As reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dan Collins

Title

President

Phone

(239) 931-7275

Specialties & licenses 1

Addresses

Other names 1

• Basil D Fossum MD Doing business as

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1315267200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598227200000",
    "number": "1427339399",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2160 COLONIAL BLVD",
            "city": "FORT MYERS",
            "state": "FL",
            "postal_code": "339071410",
            "telephone_number": "239-931-7342",
            "fax_number": "239-931-7385"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "914 MAR WALT DR",
            "address_2": "SUITE B",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325476706",
            "telephone_number": "850-226-6572",
            "fax_number": "850-862-8564"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GENESISCARE USA OF FLORIDA LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GENESISCARE USA INC.",
        "enumeration_date": "2011-09-06",
        "last_updated": "2020-08-24",
        "certification_date": "2020-08-24",
        "status": "A",
        "authorized_official_last_name": "COLLINS",
        "authorized_official_first_name": "DAN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "239-931-7275"
    },
    "taxonomies": [
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Basil D Fossum MD",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Basil D Fossum MD",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Natasha Gebhardt
• Amber Mae Gee
• Genesis Health and Wellness, LLC (Premier Interventional Pain Solutions)
• Genesis OBGYN PA
• Genesiscare USA of Florida LLC (Emerald Coast Urology)
• Genoa Healthcare LLC
• Amber Lynn Gentry, LMHC
• George D. Edlund O.D., P.a.
• Erica A. George-Saintilus, MD
• Ciara C George, PA-C

• Urology Physician in Fort Walton Beach, FL
• Providers in Fort Walton Beach, FL by specialty
• Urology Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 24, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.