Basic Information
| Provider Information | |||||||||
| NPI: | 1508947342 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA CANCER INSTITUTE, LLC | ||||||||
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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: | 7575944006 | ||||||||
| FaxNumber: | 7575345190 | ||||||||
| Practice Location | |||||||||
| Address1: | 12100 WARWICK BLVD. | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236012365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575345555 | ||||||||
| FaxNumber: | 7575345569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | BRADEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7575944006 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0101043974 | VA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 207RH0003X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0101047727 | 05 | VA | MEDICAID | 010125626 | 05 | VA | MEDICAID | 010162338 | 05 | VA | MEDICAID | 010202761 | 05 | VA | MEDICAID | 010228484 | 05 | VA | MEDICAID |