Basic Information
| Provider Information | |||||||||
| NPI: | 1306383781 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA CANCER INSTITUTE LLC | ||||||||
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| OtherOrganizationName: | TAPPAHANNOCK CANCER INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 J CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236011318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573165800 | ||||||||
| FaxNumber: | 7575345190 | ||||||||
| Practice Location | |||||||||
| Address1: | 659 HOSPITAL RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | TAPPAHANNOCK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 225607000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044436139 | ||||||||
| FaxNumber: | 8044436128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2017 | ||||||||
| LastUpdateDate: | 01/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | BRADEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7573165800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.