Basic Information
| Provider Information | |||||||||
| NPI: | 1669075891 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4371 VERONICA S SHOEMAKER BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339162216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8440 MURANO DEL LAGO DR | ||||||||
| Address2: | |||||||||
| City: | ESTERO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341358615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392215402 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2020 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILTSHIRE | ||||||||
| AuthorizedOfficialFirstName: | ROXANE | ||||||||
| AuthorizedOfficialMiddleName: | CHERYL | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR OF CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 2392243159 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No ID Information.