Provider Demographics
NPI:1629603568
Name:FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC
Entity Type:Organization
Organization Name:FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCIO
Authorized Official - Middle Name:NAVARRO
Authorized Official - Last Name:GORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-274-8200
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:2955 BROWNWOOD BLVD
Practice Address - Street 2:107
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32163-2040
Practice Address - Country:US
Practice Address - Phone:352-765-7100
Practice Address - Fax:352-430-0210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-11
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014926733Medicaid