Basic Information
Provider Information | |||||||||
NPI: | 1790054872 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLORIDA CANCER AFFILIATES PL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11373 CORTEZ BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | BROOKSVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 346135414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3525974998 | ||||||||
FaxNumber: | 3525966051 | ||||||||
Practice Location | |||||||||
Address1: | 11373 CORTEZ BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | BROOKSVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 346135414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3525974998 | ||||||||
FaxNumber: | 3525966051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2011 | ||||||||
LastUpdateDate: | 05/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROBBINS | ||||||||
AuthorizedOfficialFirstName: | GERALD | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7274847722 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 207RH0003X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 004381500 | 05 | FL |   | MEDICAID | 265199800 | 05 | FL |   | MEDICAID |