Provider Demographics
NPI:1396701546
Name:NORTH STATE CANCER SPECIALTY INC
Entity type:Organization
Organization Name:NORTH STATE CANCER SPECIALTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:L
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-242-8822
Mailing Address - Street 1:PO BOX 496084
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-6084
Mailing Address - Country:US
Mailing Address - Phone:530-241-0473
Mailing Address - Fax:530-241-5377
Practice Address - Street 1:2510 AIRPARK DR
Practice Address - Street 2:SUITE 103
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001
Practice Address - Country:US
Practice Address - Phone:530-242-8822
Practice Address - Fax:530-242-0849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-056102F207RH0003X
CAG73860207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G738600Medicaid
CAZZZ25250ZMedicare ID - Type Unspecified
CA00G738600Medicaid