Provider Demographics
NPI:1407841810
Name:TREASURE COAST CANCER CARE CENTER INC
Entity Type:Organization
Organization Name:TREASURE COAST CANCER CARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIVA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BELLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-398-6016
Mailing Address - Street 1:1700 SE HILLMOOR DR
Mailing Address - Street 2:STE 306
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7539
Mailing Address - Country:US
Mailing Address - Phone:772-398-6016
Mailing Address - Fax:772-337-0320
Practice Address - Street 1:1700 SE HILLMOOR DR
Practice Address - Street 2:STE 306
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7539
Practice Address - Country:US
Practice Address - Phone:772-398-6016
Practice Address - Fax:772-337-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070221207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31481OtherBLUECROSS BLUESHIELD
FL235170784OtherTRICARE
FL250467700Medicaid
FL2967902005OtherCIGNA
FL830005561OtherRAIL ROAD MEDICARE
FL31481OtherBLUECROSS BLUESHIELD
FLAH512Medicare PIN