1902893902 NPI number — NORTH FLORIDA CANCER CENTER LAKE CITY LLC

Table of content: (NPI 1902893902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902893902 NPI number — NORTH FLORIDA CANCER CENTER LAKE CITY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH FLORIDA CANCER CENTER LAKE CITY 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:
1902893902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
795 SW STATE ROAD 47
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32025-0453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-758-7822
Provider Business Mailing Address Fax Number:
386-758-2224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
795 SW HIGHWAY 47
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-758-7822
Provider Business Practice Location Address Fax Number:
386-758-2224
Provider Enumeration Date:
10/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GLADNEY
Authorized Official First Name:
JOAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
REGIONAL DIRECTOR
Authorized Official Telephone Number:
352-474-6190

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: 272085000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 74629 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DD1689 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 109506100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com