Basic Information
| Provider Information | |||||||||
| NPI: | 1922057850 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENDERSON CANCER CENTER PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15040 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477160040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124761367 | ||||||||
| FaxNumber: | 8124774153 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424202784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708270255 | ||||||||
| FaxNumber: | 2708265342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 09/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | KORBA | ||||||||
| AuthorizedOfficialFirstName: | ALVIN | ||||||||
| AuthorizedOfficialMiddleName: | NONE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2708260255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MEDICAL DOCTOR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | CA0138 | 01 | KY | RR MEDICARE | OTHER | 65913774 | 05 | KY | MEDICAID |