Provider Demographics
NPI:1891748257
Name:FLORIDA PROTON THERAPY INSTITUTE INC
Entity Type:Organization
Organization Name:FLORIDA PROTON THERAPY INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, ACTIVE, ATTENDING
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDENHALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-588-1263
Mailing Address - Street 1:2015 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-3531
Mailing Address - Country:US
Mailing Address - Phone:904-588-1239
Mailing Address - Fax:904-588-1300
Practice Address - Street 1:2015 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-3531
Practice Address - Country:US
Practice Address - Phone:904-588-1263
Practice Address - Fax:904-588-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME390542085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2771470 00Medicaid
FLQ0285Medicare PIN