Provider Demographics
NPI:1083857940
Name:PENINSULA CANCER CENTER LLC
Entity Type:Organization
Organization Name:PENINSULA CANCER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:NEZAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TOOLOEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-755-1825
Mailing Address - Street 1:PO BOX 742322
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2322
Mailing Address - Country:US
Mailing Address - Phone:360-697-8000
Mailing Address - Fax:
Practice Address - Street 1:19917 7TH AVE NE
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7403
Practice Address - Country:US
Practice Address - Phone:360-697-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-08
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8883801Medicare PIN
WAG8883800Medicare PIN
WAG8883799Medicare PIN