1679524714 NPI number — CAROLINA REGIONAL CANCER CENTER LLC

Table of content: (NPI 1679524714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679524714 NPI number — CAROLINA REGIONAL CANCER CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA REGIONAL CANCER CENTER 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:
6
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:
1679524714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1419 SE 8TH TER STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE CORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33990-3213
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:
4708 OLEANDER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-449-9415
Provider Business Practice Location Address Fax Number:
843-449-2160
Provider Enumeration Date:
05/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARZOUK
Authorized Official First Name:
SHADEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
239-931-7254

Provider Taxonomy Codes

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

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

  • Identifier: GP0968 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG7705 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8902260 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 503356 . This is a "BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02260 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 9620580 . This is a "GHI" identifier . This identifiers is of the category "OTHER".




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