Basic Information
| Provider Information | |||||||||
| NPI: | 1902893902 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH FLORIDA CANCER CENTER LAKE CITY LLC | ||||||||
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| OtherOrganizationName: | THE CANCER CENTER AT LAKE CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 795 SW STATE ROAD 47 | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320250453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867587822 | ||||||||
| FaxNumber: | 3867582224 | ||||||||
| Practice Location | |||||||||
| Address1: | 795 SW HIGHWAY 47 | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867587822 | ||||||||
| FaxNumber: | 3867582224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | GLADNEY | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3524746190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 272085000 | 05 | FL | MEDICAID | 74629 | 01 | FL | BCBS | OTHER | DD1689 | 01 | FL | RR MEDICARE | OTHER |