Provider Demographics
NPI:1609984301
Name:PROGRESSIVE CANCER CARE LLC
Entity Type:Organization
Organization Name:PROGRESSIVE CANCER CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUGHMAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-662-4293
Mailing Address - Street 1:PO BOX 1083
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1083
Mailing Address - Country:US
Mailing Address - Phone:317-802-6318
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:831 N THEATRE RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1701
Practice Address - Country:US
Practice Address - Phone:765-662-4293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200507020Medicaid
IN200507020Medicaid