1659381549 NPI number — CANCER THERAPY MEDICAL GROUP INC

Table of content: (NPI 1659381549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659381549 NPI number — CANCER THERAPY MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANCER THERAPY MEDICAL GROUP 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:
FRESNO CANCER CENTER & CENTRAL VALLEY BREAST CARE
Provider Other Organization Name Type Code:
3
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:
1659381549
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 756
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94526-0756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-866-0914
Provider Business Mailing Address Fax Number:
209-343-3809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7887 N CEDAR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93720-2685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-437-1000
Provider Business Practice Location Address Fax Number:
559-437-3870
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUMPHREY
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
925-952-8700

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QX0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0092411 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DC7191 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZZZ208856Z . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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