Provider Demographics
NPI:1215943675
Name:FAMILY CANCER CENTER, PLLC
Entity type:Organization
Organization Name:FAMILY CANCER CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-685-5655
Mailing Address - Street 1:P.O. BOX 5111
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-5111
Mailing Address - Country:US
Mailing Address - Phone:901-685-5655
Mailing Address - Fax:901-685-2590
Practice Address - Street 1:6029 WALNUT GROVE
Practice Address - Street 2:SUITE 301
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-747-9081
Practice Address - Fax:901-379-0532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19652174400000X
TNMD0000015925207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS090015910Medicaid
AR135396002Medicaid
TNCG9522OtherRRMCR
TN4035183OtherBCBS
TN3723894Medicaid
TN=========OtherTAX ID/EIN
TN4035183OtherBCBS
AR135396002Medicaid