Basic Information
| Provider Information | |||||||||
| NPI: | 1720670490 | ||||||||
| 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 | ||||||||
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| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339162216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2202 STATE AVE STE 102 | ||||||||
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| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324054539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884966621 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2021 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | GORDAN | ||||||||
| AuthorizedOfficialFirstName: | LUCIO | ||||||||
| AuthorizedOfficialMiddleName: | NAVARRO | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3523323900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
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 |