Provider Demographics
NPI:1659381549
Name:CANCER THERAPY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CANCER THERAPY MEDICAL GROUP INC
Other - Org Name:FRESNO CANCER CENTER & CENTRAL VALLEY BREAST CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-952-8700
Mailing Address - Street 1:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-0756
Mailing Address - Country:US
Mailing Address - Phone:877-866-0914
Mailing Address - Fax:209-343-3809
Practice Address - Street 1:7887 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2685
Practice Address - Country:US
Practice Address - Phone:559-437-1000
Practice Address - Fax:559-437-3870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANCER THERAPY MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-09
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0092411Medicaid
DC7191OtherRAILROAD MEDICARE
ZZZ208856ZOtherBLUE SHIELD
CAZZZ25334ZMedicare ID - Type UnspecifiedMCARE GROUP