Provider Demographics
NPI:1043220627
Name:CHARLESTON CANCER CENTER PA
Entity Type:Organization
Organization Name:CHARLESTON CANCER CENTER PA
Other - Org Name:TRIDENT PALMETTO HEMATOLOGY ONCOLOGY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:MICHAELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-572-9211
Mailing Address - Street 1:2910 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9350
Mailing Address - Country:US
Mailing Address - Phone:843-572-9211
Mailing Address - Fax:843-572-0457
Practice Address - Street 1:2910 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9350
Practice Address - Country:US
Practice Address - Phone:843-572-9211
Practice Address - Fax:843-572-0457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0003X
SC11628207RH0003X
SC18607207RH0003X
SC19684207RH0003X
SC32155207RH0003X
SC30018207RH0003X
SCPA2273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C612826292OtherMEDICARE GROUP NUMBER
1278940001Medicare NSC