Basic Information
| Provider Information | |||||||||
| NPI: | 1609984301 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESSIVE CANCER CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1083 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178026318 | ||||||||
| FaxNumber: | 3178700499 | ||||||||
| Practice Location | |||||||||
| Address1: | 831 N THEATRE RD | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469521701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656624293 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 09/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | MUGHMAW | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7656624293 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 200507020 | 05 | IN | MEDICAID |