1609984301 NPI number — PROGRESSIVE CANCER CARE LLC

Table of content: (NPI 1609984301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609984301 NPI number — PROGRESSIVE CANCER CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESSIVE CANCER CARE 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:
1609984301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1083
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46206-1083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-802-6318
Provider Business Mailing Address Fax Number:
317-870-0499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
831 N THEATRE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46952-1701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-662-4293
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUGHMAW
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
765-662-4293

Provider Taxonomy Codes

  • Taxonomy code: 261QX0203X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200507020 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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