Basic Information
| Provider Information | |||||||||
| NPI: | 1396701546 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH STATE CANCER SPECIALTY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 496084 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960496084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302410473 | ||||||||
| FaxNumber: | 5302415377 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 AIRPARK DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302428822 | ||||||||
| FaxNumber: | 5302420849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | FREEMAN | ||||||||
| AuthorizedOfficialFirstName: | JED | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES | ||||||||
| AuthorizedOfficialTelephone: | 5302428822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 35-056102F | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | G73860 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00G738600 | 05 | CA | MEDICAID |