Basic Information
| Provider Information | |||||||||
| NPI: | 1598745945 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIGGUNDU RADIATION THERAPY, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | 21ST CENTURY ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 COLONIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 MIDDLEFORD RD | ||||||||
| Address2: | |||||||||
| City: | SEAFORD | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199733636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026296611 | ||||||||
| FaxNumber: | 3026283972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | KIGGUNDU | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2399317342 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0000987802 | 05 | DE | MEDICAID | 200106302 | 05 | MD | MEDICAID | 200106301 | 05 | MD | MEDICAID |