Basic Information
| Provider Information | |||||||||
| NPI: | 1336228949 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANCER INSTITUTE OF CAPE GIRARDEAU, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 DOCTORS PARK | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637034928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733342230 | ||||||||
| FaxNumber: | 5736516499 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 DOCTORS PARK | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637034928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733342230 | ||||||||
| FaxNumber: | 5736516499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | LUTTRELL | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLER/CODER | ||||||||
| AuthorizedOfficialTelephone: | 5733315916 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ROCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0203X | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation |
ID Information
| ID | Type | State | Issuer | Description | 514063 | 01 | MO | HEALTHLINK PROVIDER ID | OTHER |