Provider Demographics
NPI:1629304423
Name:COMPREHENSIVE CANCER CARE, PC
Entity Type:Organization
Organization Name:COMPREHENSIVE CANCER CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KLIX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-443-6465
Mailing Address - Street 1:PO BOX 190820
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-6820
Mailing Address - Country:US
Mailing Address - Phone:314-443-6465
Mailing Address - Fax:
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8657
Practice Address - Country:US
Practice Address - Phone:314-443-6465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-29
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112773207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========OtherDEPARTMENT OF TREASURY