1215101902 NPI number — 21ST CENTURY ONCOLOGY OF JACKSONVILLE LLC

Table of content: (NPI 1215101902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215101902 NPI number — 21ST CENTURY ONCOLOGY OF JACKSONVILLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
21ST CENTURY ONCOLOGY OF JACKSONVILLE LLC
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:
Provider Other Organization Name Type Code:
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:
1215101902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1235 SAN MARCO BLVD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-8554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-493-5100
Provider Business Practice Location Address Fax Number:
904-493-5130
Provider Enumeration Date:
04/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DOSORETZ
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
239-931-7275

Provider Taxonomy Codes

  • Taxonomy code: 207RX0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086X0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 281173104 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 281173100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 281173101 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 281173102 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 281173103 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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