Provider Demographics
NPI:1821250945
Name:VALDOSTA BLOOD AND CANCER CENTER
Entity Type:Organization
Organization Name:VALDOSTA BLOOD AND CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAGENDER
Authorized Official - Middle Name:
Authorized Official - Last Name:MANKAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-259-4616
Mailing Address - Street 1:1172 OLD MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7938
Mailing Address - Country:US
Mailing Address - Phone:229-232-4449
Mailing Address - Fax:
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:PEARLMAN COMPREHENSIVE CANCER CENTER
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1735
Practice Address - Country:US
Practice Address - Phone:229-259-4616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057887207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI55879Medicare UPIN