Basic Information
| Provider Information | |||||||||
| NPI: | 1083661607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALIFORNIA CANCER ASSOCIATES FOR RESEARCH AND EXCELLENCE,INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 WOODMONT BLVD STE 500 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152527212 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7130 N MILLBROOK AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593261222 | ||||||||
| FaxNumber: | 5593261230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | MONSON | ||||||||
| AuthorizedOfficialFirstName: | JEDIDIAH | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6152527212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207RH0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 2086X0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | CS0991 | 01 | CA | RAILROAD MEDICARE | OTHER | ZZZ37565Z | 01 | CA | MEDICARE PTAN | OTHER | G1563A | 01 | CA | SOUTHERN CALIF MEDICARE PTAN | OTHER |