Basic Information
| Provider Information | |||||||||
| NPI: | 1093174377 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACKERMAN CANCER CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10881 SAN JOSE BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322236612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042603022 | ||||||||
| FaxNumber: | 9042603947 | ||||||||
| Practice Location | |||||||||
| Address1: | 1895 KINGSLEY AVE | ||||||||
| Address2: | SUITE 903 | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046448353 | ||||||||
| FaxNumber: | 9046448289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2016 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | ACKERMAN | ||||||||
| AuthorizedOfficialFirstName: | SCOT | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9042603022 | ||||||||
| 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 | 208800000X | ME92864 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 006734700 | 05 | FL | MEDICAID |