Provider Demographics
NPI:1962652180
Name:MONTGOMERY CANCER CENTER, LLC
Entity Type:Organization
Organization Name:MONTGOMERY CANCER CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VENTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-273-2285
Mailing Address - Street 1:4145 CARMICHAEL RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2803
Mailing Address - Country:US
Mailing Address - Phone:334-273-7000
Mailing Address - Fax:
Practice Address - Street 1:1023 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6780
Practice Address - Country:US
Practice Address - Phone:334-872-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF836Medicare PIN
4248810004Medicare NSC