Basic Information
| Provider Information | |||||||||
| NPI: | 1215101902 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 21ST CENTURY ONCOLOGY OF JACKSONVILLE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 1235 SAN MARCO BLVD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044935100 | ||||||||
| FaxNumber: | 9044935130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | DOSORETZ | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2399317275 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADIATION THERAPY SERVICES INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 207RX0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 281173104 | 05 | FL | MEDICAID | 281173100 | 05 | FL | MEDICAID | 281173101 | 05 | FL | MEDICAID | 281173102 | 05 | FL | MEDICAID | 281173103 | 05 | FL | MEDICAID |