Provider Demographics
NPI: | 1265044804 |
---|---|
Name: | GENESISCARE LANDMARK MISSOURI CANCER CARE PC |
Entity Type: | Organization |
Organization Name: | GENESISCARE LANDMARK MISSOURI CANCER CARE PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JEFFREY |
Authorized Official - Middle Name: | T |
Authorized Official - Last Name: | TRIPLETTE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 314-665-3096 |
Mailing Address - Street 1: | 2160 COLONIAL BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT MYERS |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33907-1410 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 239-931-7342 |
Mailing Address - Fax: | 239-931-7385 |
Practice Address - Street 1: | 450 N NEW BALLAS RD STE 70W |
Practice Address - Street 2: | |
Practice Address - City: | SAINT LOUIS |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63141-6833 |
Practice Address - Country: | US |
Practice Address - Phone: | 314-665-3096 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-08-17 |
Last Update Date: | 2020-08-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 2085R0001X | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | Group - Single Specialty |