Basic Information
| Provider Information | |||||||||
| NPI: | 1912178682 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANCER CONTROL CENTER OF CHARLESTON,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100523 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295010523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 BEN SAWYER BLVD | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294645519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438848121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 03/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | NIXON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8438848121 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 17188 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | GP4232 | 05 | SC | MEDICAID |