Provider Demographics
NPI: | 1275917304 |
---|---|
Name: | 21ST CENTURY ONCOLOGY LLC |
Entity Type: | Organization |
Organization Name: | 21ST CENTURY ONCOLOGY LLC |
Other - Org Name: | GULFSHORE UROLOGY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KIM |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | COMMINS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 239-931-7277 |
Mailing Address - Street 1: | 2234 COLONIAL BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT MYERS |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33907-1412 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 239-931-7342 |
Mailing Address - Fax: | 239-931-7385 |
Practice Address - Street 1: | 4571 COLONIAL BLVD |
Practice Address - Street 2: | |
Practice Address - City: | FORT MYERS |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33966-1156 |
Practice Address - Country: | US |
Practice Address - Phone: | 239-322-5600 |
Practice Address - Fax: | 239-322-5610 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | 21ST CENTURY ONCOLOGY INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2015-07-18 |
Last Update Date: | 2019-07-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Single Specialty |