1063581536 NPI number — SOUTHEAST CANCER NETWORK, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063581536 NPI number — SOUTHEAST CANCER NETWORK, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST CANCER NETWORK, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTHWEST REGIONAL CANCER CENTER
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063581536
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 AFFLINK PL
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
TUSCALOOSA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35406-2289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-366-9740
Provider Business Mailing Address Fax Number:
205-344-9992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
171 CARAWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINFIELD
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35594-5067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-487-4405
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
205-366-9740

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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