Provider Demographics
NPI:1396132213
Name:LAKE CITY CANCER CARE LLC
Entity type:Organization
Organization Name:LAKE CITY CANCER CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RHYMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-467-7415
Mailing Address - Street 1:289 SW STONEGATE TER
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-3456
Mailing Address - Country:US
Mailing Address - Phone:386-755-1655
Mailing Address - Fax:386-628-9231
Practice Address - Street 1:289 SW STONEGATE TER
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-3456
Practice Address - Country:US
Practice Address - Phone:386-755-1655
Practice Address - Fax:386-628-9231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC10421207RH0003X, 207RX0202X
FLHCC10606208800000X
FLHCC84142085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015614300Medicaid
FLIE881AMedicare PIN