Provider Demographics
NPI:1578629556
Name:SOUTHERN CANCER CENTER, PC
Entity Type:Organization
Organization Name:SOUTHERN CANCER CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN/OCN
Authorized Official - Phone:251-625-6896
Mailing Address - Street 1:29653 ANCHOR CROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9594
Mailing Address - Country:US
Mailing Address - Phone:251-625-6896
Mailing Address - Fax:251-625-6897
Practice Address - Street 1:6701 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-6705
Practice Address - Country:US
Practice Address - Phone:251-625-6896
Practice Address - Fax:251-266-3209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL280449Medicaid
AL529932160Medicaid
AL148349Medicaid
AL216459Medicaid
AL221523Medicaid
AL262637Medicaid
AL279717Medicaid
AL529932140Medicaid
AL529932170Medicaid