1912786963 NPI number — ACKERMAN CANCER CENTER, PA

Table of content: (NPI 1912786963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912786963 NPI number — ACKERMAN CANCER CENTER, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACKERMAN CANCER CENTER, PA
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:
1912786963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10881 SAN JOSE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32223-6612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-880-5522
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
533 W TWINCOURT TRL STE 701
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32095-8884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-490-7400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ACKERMAN
Authorized Official First Name:
SCOT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-880-5522

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 253854704 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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