Provider Demographics
NPI:1497737183
Name:CANCER CENTER ONCOLOGY MEDICAL GROUP, INC-EAST COUNTY
Entity Type:Organization
Organization Name:CANCER CENTER ONCOLOGY MEDICAL GROUP, INC-EAST COUNTY
Other - Org Name:CANCER CENTER ONCOLOGY MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-644-3030
Mailing Address - Street 1:5555 GROSSMONT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3019
Mailing Address - Country:US
Mailing Address - Phone:619-644-3030
Mailing Address - Fax:619-644-3083
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-644-3030
Practice Address - Fax:619-644-3638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26407174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ40281ZOtherGROUP BLUE SHIELD
CAGR0057640Medicaid
CA6204230001Medicare NSC
CAW12245Medicare ID - Type UnspecifiedGROUP MEDICARE