Basic Information
| Provider Information | |||||||||
| NPI: | 1184626590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GENETOS | ||||||||
| FirstName: | BASIL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3926 NEW VISION DR | ||||||||
| Address2: | SUITE3 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603737875 | ||||||||
| FaxNumber: | 2603739705 | ||||||||
| Practice Location | |||||||||
| Address1: | 11108 PARKVIEW CIRCLE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602665700 | ||||||||
| FaxNumber: | 2602665920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 11/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 01024857A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 100186010 | 05 | IN | MEDICAID | 060070579 | 01 | IN | RR MEDICARE | OTHER | 000000641079 | 01 | IN | ANTHEM | OTHER | 0528012 | 05 | OH | MEDICAID |