Basic Information
| Provider Information | |||||||||
| NPI: | 1992710800 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY CANCER CENTER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 242173 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381242173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018500272 | ||||||||
| FaxNumber: | 9018500782 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 S MILES AVE | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318841412 | ||||||||
| FaxNumber: | 7318841720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 07/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | WALSH | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9016855655 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 23524 | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 4035183 | 01 | TN | BCBS | OTHER | CG9522 | 01 | TN | RRMCR | OTHER | 3723894 | 05 | TN | MEDICAID | 135396002 | 05 | AR | MEDICAID |