Basic Information
| Provider Information | |||||||||
| NPI: | 1679524714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA REGIONAL CANCER CENTER LLC | ||||||||
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| OtherOrganizationName: | CAROLINA REGIONAL CANCER CENTER INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2270 COLONIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 4708 OLEANDER DRIVE | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434499415 | ||||||||
| FaxNumber: | 8434492160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2399317277 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | CG7705 | 01 | RAILROAD MEDICARE | OTHER | 503356 | 01 | PA | BCBS | OTHER | 02260 | 01 | NC | BCBS | OTHER | 8902260 | 05 | NC | MEDICAID | 9620580 | 01 | GHI | OTHER | GP0968 | 05 | SC | MEDICAID |