Individual
BASIL C GENETOS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
11108 PARKVIEW CIRCLE DR, FORT WAYNE, IN 46845-1730
(260) 266-5700
(260) 266-5920
Mailing address
3926 NEW VISION DR, SUITE3, FORT WAYNE, IN 46845-1712
(260) 373-7875
(260) 373-9705
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
01024857A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000641079
ANTHEM
IN
05
—
0528012
—
OH
01
—
060070579
RR MEDICARE
IN
05
—
100186010
—
IN
Enumeration date
08/15/2005
Last updated
11/28/2016
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