| Genesis Family Practice, Llc | |
|
1133 Saxon Blvd Orange City FL 32763-8425 | |
| (386) 228-9700 | |
| Not Available |
| Full Name | Genesis Family Practice, Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 1133 Saxon Blvd, Orange City, Florida |
| Authorized Official Name and Position | Jay Crossette Chanmugam (OWNER) |
| Authorized Official Contact | 3868784137 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Genesis Family Practice, Llc 1133 Saxon Blvd Orange City FL 32763-8425 Ph: (386) 878-4137 | Genesis Family Practice, Llc 1133 Saxon Blvd Orange City FL 32763-8425 Ph: (386) 228-9700 |
| NPI Number | 1023369204 |
|---|---|
| Provider Enumeration Date | 09/27/2012 |
| Last Update Date | 11/28/2022 |
| Medicare PECOS PAC ID | 8921253816 |
|---|---|
| Medicare Enrollment ID | O20130226000215 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1023369204 | NPI | - | NPPES |
| 008488100 | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | OS8600 (Florida) | Primary |
| 291U00000X | Clinical Medical Laboratory | (* (Not Available)) | Secondary |
| Provider Name | Jay C Chanmugam |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1518905207 PECOS PAC ID: 7911898556 Enrollment ID: I20041214000460 |
| Provider Name | Sylvia H Collazo |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1063435592 PECOS PAC ID: 4688560931 Enrollment ID: I20160608000007 |
| Provider Name | Cesar Omar Corretjer Russi |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1164619367 PECOS PAC ID: 1153487251 Enrollment ID: I20170613000405 |
| Provider Name | April Renee Gustafson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1811473275 PECOS PAC ID: 5890046239 Enrollment ID: I20180924001386 |
| Provider Name | Aixsa Perez |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1639171853 PECOS PAC ID: 0143556530 Enrollment ID: I20190723002064 |
| Provider Name | Cameka Campbell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1043753437 PECOS PAC ID: 6103240940 Enrollment ID: I20200727000698 |
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