Basic Information
| Provider Information | |||||||||
| NPI: | 1629275565 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST CANCER NETWORK INC | ||||||||
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| OtherOrganizationName: | CANCER CARE CENTER OF MONTGOMERY PRATTVILLE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 AFFLINK PL STE 100 | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354062289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053669740 | ||||||||
| FaxNumber: | 2053449992 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 MCQUEEN SMITH RD N | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PRATTVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360665561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343587791 | ||||||||
| FaxNumber: | 3343587751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2053669740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 2085R0001X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.