Basic Information
| Provider Information | |||||||||
| NPI: | 1144504457 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOSTON BASKIN CANCER FOUNDATION, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 405827 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303849446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 HUMPHREYS CENTER DR STE 330 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017526131 | ||||||||
| FaxNumber: | 9017526167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | RATLIFF | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9017674520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 31689 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1526936 | 05 | TN | MEDICAID | DS2782 | 01 | MS | RR MEDICARE MS | OTHER | DS5687 | 01 | AR | MEDICARE RR AR | OTHER | 2871745 | 05 | MS | MEDICAID | DS2781 | 01 | TN | RR MEDICARE TN | OTHER |