Provider Demographics
NPI:1326107871
Name:MISSOURI CANCER CARE PC
Entity Type:Organization
Organization Name:MISSOURI CANCER CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-639-8650
Mailing Address - Street 1:1078 WENTZVILLE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385
Mailing Address - Country:US
Mailing Address - Phone:636-639-8644
Mailing Address - Fax:636-639-8665
Practice Address - Street 1:400 MEDICAL PLAZA
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367
Practice Address - Country:US
Practice Address - Phone:636-639-8620
Practice Address - Fax:636-639-8665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507598704Medicaid
MO507598704Medicaid