Provider Demographics
NPI:1710180120
Name:PENINSULA CANCER INSTITUTE, LLC
Entity Type:Organization
Organization Name:PENINSULA CANCER INSTITUTE, LLC
Other - Org Name:CANCER SPECIALISTS OF TIDEWATER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LESNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-594-4006
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:110 WIMBLEDON SQ
Practice Address - Street 2:SUITE E
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4946
Practice Address - Country:US
Practice Address - Phone:757-436-2995
Practice Address - Fax:757-436-2912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09380Medicare PIN
VA6122940001Medicare NSC