Basic Information
| Provider Information | |||||||||
| NPI: | 1750694212 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA CANCER PHYSICIANS NETWORK LLC | ||||||||
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| OtherOrganizationName: | FLORIDA REGIONAL CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2715 W VIRGINIA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136626024 | ||||||||
| FaxNumber: | 8135141257 | ||||||||
| Practice Location | |||||||||
| Address1: | 3406 N LECANTO HWY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344653548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527461100 | ||||||||
| FaxNumber: | 3522912498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2010 | ||||||||
| LastUpdateDate: | 09/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | NICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP INDIANA & S FLORIDA OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8136626024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA FACHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | DR0495 | 01 | FL | RR MEDICARE | OTHER | 0014A | 01 | FL | BCBS | OTHER | 002715007 | 05 | FL | MEDICAID |