Provider Demographics
NPI:1336228949
Name:CANCER INSTITUTE OF CAPE GIRARDEAU, LLC
Entity Type:Organization
Organization Name:CANCER INSTITUTE OF CAPE GIRARDEAU, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER/CODER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:ROCC
Authorized Official - Phone:573-331-5916
Mailing Address - Street 1:14 DOCTORS PARK
Mailing Address - Street 2:SUITE B
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-334-2230
Mailing Address - Fax:573-651-6499
Practice Address - Street 1:14 DOCTORS PARK
Practice Address - Street 2:SUITE B
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-334-2230
Practice Address - Fax:573-651-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO514063OtherHEALTHLINK PROVIDER ID