Provider Demographics
NPI:1639114408
Name:PALM BEACH CANCER INSTITUTE LLC
Entity Type:Organization
Organization Name:PALM BEACH CANCER INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAN ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-366-4104
Mailing Address - Street 1:PO BOX 863310
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3310
Mailing Address - Country:US
Mailing Address - Phone:561-366-4100
Mailing Address - Fax:561-366-4189
Practice Address - Street 1:1309 N FLAGLER DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-3406
Practice Address - Country:US
Practice Address - Phone:561-366-4100
Practice Address - Fax:561-366-4189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267990604Medicaid
FL267990602Medicaid
FL267990603Medicaid
FL267990600Medicaid
FL267990601Medicaid
FL34754Medicare PIN
FL267990604Medicaid