Provider Demographics
NPI:1083942064
Name:MOFFITT CANCER CENTER & RESEARCH INSTITUTE
Entity Type:Organization
Organization Name:MOFFITT CANCER CENTER & RESEARCH INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR, HEALTH OUTCOMES & BEHAVIOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-745-1810
Mailing Address - Street 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:813-745-3862
Mailing Address - Fax:813-745-3906
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-3862
Practice Address - Fax:813-745-3906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5272284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPY5272OtherCLINICAL PSYCHOLOGY LICENSE