Basic Information
Provider Information | |||||||||
NPI: | 1346832086 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC | ||||||||
Address2: | 4371 VERONICA S SHOEMAKER BLVD. | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339162216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2392748200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2351 PHILLIPS RD | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323085333 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8884966621 | ||||||||
FaxNumber: | 8504020428 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/04/2021 | ||||||||
LastUpdateDate: | 02/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GORDAN | ||||||||
AuthorizedOfficialFirstName: | LUCIO | ||||||||
AuthorizedOfficialMiddleName: | NAVARRO | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 3523323900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 01/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VH0002X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Hospice and Palliative Medicine |
ID Information
ID | Type | State | Issuer | Description | 017684600 | 05 | FL |   | MEDICAID |