Provider Demographics
NPI:1508947342
Name:PENINSULA CANCER INSTITUTE, LLC
Entity Type:Organization
Organization Name:PENINSULA CANCER INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-594-4006
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:12100 WARWICK BLVD.
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2365
Practice Address - Country:US
Practice Address - Phone:757-534-5555
Practice Address - Fax:757-534-5569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043974174400000X
207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101047727Medicaid
VA010125626Medicaid
VA010162338Medicaid
VA010202761Medicaid
VA010228484Medicaid
VA010162338Medicaid
VA010125626Medicaid
VAG88139Medicare UPIN
VAH53415Medicare UPIN
VAF23116Medicare UPIN
VA010202761Medicaid
VAC09380Medicare PIN
VAG98699Medicare UPIN
VA010228484Medicaid