Basic Information
| Provider Information | |||||||||
| NPI: | 1710180120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA CANCER INSTITUTE, LLC | ||||||||
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| OtherOrganizationName: | CANCER SPECIALISTS OF TIDEWATER | ||||||||
| 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: | 7575944006 | ||||||||
| FaxNumber: | 7575345190 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 WIMBLEDON SQ | ||||||||
| Address2: | SUITE E | ||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233204946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574362995 | ||||||||
| FaxNumber: | 7574362912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 12/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | LESNICK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7575944006 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.