Provider Demographics
NPI:1306833595
Name:H LEE MOFFITT CANCER CTR & RES INST LIFE TIME CANCER SCRN CTR INC
Entity Type:Organization
Organization Name:H LEE MOFFITT CANCER CTR & RES INST LIFE TIME CANCER SCRN CTR INC
Other - Org Name:MOFFITT MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-745-4673
Mailing Address - Street 1:PO BOX 198441
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8441
Mailing Address - Country:US
Mailing Address - Phone:866-761-5658
Mailing Address - Fax:
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:813-745-4673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373056500Medicaid
FL10D0965510OtherCLIA
FL24755OtherBCBS
FL3400057OtherUNITED HEALTHCARE
FL10D0965510OtherCLIA
FL3400057OtherUNITED HEALTHCARE