Provider Demographics
NPI:1174690721
Name:INTERNATIONAL CANCER FOUNDATION
Entity Type:Organization
Organization Name:INTERNATIONAL CANCER FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-593-7525
Mailing Address - Street 1:1989 N HIGHWAY 341
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30741-6204
Mailing Address - Country:US
Mailing Address - Phone:423-593-7525
Mailing Address - Fax:706-858-1287
Practice Address - Street 1:1989 N HIGHWAY 341
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-6204
Practice Address - Country:US
Practice Address - Phone:423-593-7525
Practice Address - Fax:706-858-1287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD28389Medicare UPIN