Provider Demographics
NPI:1437209632
Name:BLOOD & CANCER CLINIC, P.A.
Entity Type:Organization
Organization Name:BLOOD & CANCER CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHIRISH
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEVASTHALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-483-8586
Mailing Address - Street 1:PO BOX 53095
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-3095
Mailing Address - Country:US
Mailing Address - Phone:910-483-8586
Mailing Address - Fax:910-483-9212
Practice Address - Street 1:1565 PURDUE DR
Practice Address - Street 2:SUITE 301
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5536
Practice Address - Country:US
Practice Address - Phone:910-483-8586
Practice Address - Fax:910-483-9212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38929207RH0003X
NC200401286207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011G3OtherBCBSNC
NC89011G3Medicaid
NC89011G3Medicaid