Provider Demographics
NPI:1508876400
Name:CANCER THERAPY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CANCER THERAPY MEDICAL GROUP INC
Other - Org Name:SOUTH SACRAMENTO CANCER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-952-8700
Mailing Address - Street 1:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-0756
Mailing Address - Country:US
Mailing Address - Phone:877-866-0914
Mailing Address - Fax:209-343-3809
Practice Address - Street 1:8100 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2353
Practice Address - Country:US
Practice Address - Phone:916-683-9616
Practice Address - Fax:916-688-1320
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANCER THERAPY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-09
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA253850OtherMEDICARE
ZZZ50269ZOtherBLUE SHIELD
DC7191OtherRAILROAD MEDICARE
ZZZ50269ZOtherBLUE SHIELD