Basic Information
| Provider Information | |||||||||
| NPI: | 1124117841 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUGAR CREEK CANCER CENTER L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 324 EMERSON RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HIGH RIDGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630492542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366771800 | ||||||||
| FaxNumber: | 6366778800 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 EMERSON RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HIGH RIDGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630492542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366771800 | ||||||||
| FaxNumber: | 6366778800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONTI | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6366771800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | R5635 | MO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | R5409 | MO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.