Provider Demographics
NPI:1740477595
Name:LEE CANCER CLINIC PLLC
Entity type:Organization
Organization Name:LEE CANCER CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BHANUPRASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KONERU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-278-1911
Mailing Address - Street 1:12781 WORLD PLAZA LN STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4078
Mailing Address - Country:US
Mailing Address - Phone:239-278-1911
Mailing Address - Fax:239-278-4511
Practice Address - Street 1:12781 WORLD PLAZA LN
Practice Address - Street 2:UNIT 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4078
Practice Address - Country:US
Practice Address - Phone:239-278-1911
Practice Address - Fax:239-278-4511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 75079207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6032OtherMEDICARE GROUP SENDER