Provider Demographics
NPI:1407862899
Name:FAMILY CANCER CENTER, PLLC
Entity Type:Organization
Organization Name:FAMILY CANCER CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-685-5655
Mailing Address - Street 1:P.O. BOX 5111
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-5111
Mailing Address - Country:US
Mailing Address - Phone:901-685-5655
Mailing Address - Fax:901-685-2590
Practice Address - Street 1:391 SOUTHCREST CIR
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4848
Practice Address - Country:US
Practice Address - Phone:662-349-0755
Practice Address - Fax:662-349-0356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19652174400000X
MS18137207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS090015910Medicaid
MS0090015910Medicaid
MSCK3826OtherRRMCR
MSCK3826OtherRRMCR
MS0090015910Medicaid
MS=========OtherBCBS
TN=========OtherTAX ID/EIN