Basic Information
| Provider Information | |||||||||
| NPI: | 1003972555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORIDA CANCER SPECIALISTS P L | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | ATTN: CREDENTIAL DEPARTMENT | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | 2392783350 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 MANATEE AVE E | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342081143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417482217 | ||||||||
| FaxNumber: | 9417485300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | GORDAN | ||||||||
| AuthorizedOfficialFirstName: | LUCIO | ||||||||
| AuthorizedOfficialMiddleName: | NAVARRO | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2392748200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 254016916 | 05 | FL | MEDICAID |