Provider Demographics
NPI:1679524714
Name:CAROLINA REGIONAL CANCER CENTER LLC
Entity Type:Organization
Organization Name:CAROLINA REGIONAL CANCER CENTER LLC
Other - Org Name:CAROLINA REGIONAL CANCER CENTER INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARZOUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-931-7254
Mailing Address - Street 1:1419 SE 8TH TER STE 200
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3213
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:4708 OLEANDER DRIVE
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:843-449-9415
Practice Address - Fax:843-449-2160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0968Medicaid
CG7705OtherRAILROAD MEDICARE
NC8902260Medicaid
PA503356OtherBCBS
NC02260OtherBCBS
9620580OtherGHI
PA503356OtherBCBS
SCGP0968Medicaid