Provider Demographics
NPI:1528369667
Name:CHARLESTON CANCER CENTER, PA
Entity Type:Organization
Organization Name:CHARLESTON CANCER CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE & BENEFITS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MELODY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:843-576-1354
Mailing Address - Street 1:2910 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9350
Mailing Address - Country:US
Mailing Address - Phone:843-572-9211
Mailing Address - Fax:843-572-0457
Practice Address - Street 1:730 STONY LANDING RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-2904
Practice Address - Country:US
Practice Address - Phone:843-572-9211
Practice Address - Fax:843-572-9120
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLESTON CANCER CENTER, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2200Medicaid
SC6292Medicare PIN