Provider Demographics
NPI:1588724033
Name:MEMORIAL SOUTHSIDE CANCER CENTER LLC
Entity type:Organization
Organization Name:MEMORIAL SOUTHSIDE CANCER CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:5742 BOOTH RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207
Mailing Address - Country:US
Mailing Address - Phone:904-636-6911
Mailing Address - Fax:904-636-6330
Practice Address - Street 1:5742 BOOTH RD
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-636-6911
Practice Address - Fax:904-636-6330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPPLYING261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDG1361OtherRR MEDICARE
FL00389OtherBCBS OF FL
FL277325200Medicaid
FLDG1361OtherRR MEDICARE