Provider Demographics
NPI:1861689424
Name:PALM COAST ONCOLOGY
Entity Type:Organization
Organization Name:PALM COAST ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:NDEP
Authorized Official - Last Name:NDUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-586-2889
Mailing Address - Street 1:61 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:SUITE 3808
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5981
Mailing Address - Country:US
Mailing Address - Phone:386-586-2889
Mailing Address - Fax:386-586-2890
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:SUITE 3808
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5981
Practice Address - Country:US
Practice Address - Phone:386-586-2889
Practice Address - Fax:386-586-2890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88511207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME88511OtherSTATE MEDICAL LICENSE
FL=========OtherTAX ID NUMBER
FLME88511OtherSTATE MEDICAL LICENSE
FLH31618Medicare UPIN
81334SMedicare PIN