Provider Demographics
NPI:1902893902
Name:NORTH FLORIDA CANCER CENTER LAKE CITY LLC
Entity Type:Organization
Organization Name:NORTH FLORIDA CANCER CENTER LAKE CITY LLC
Other - Org Name:THE CANCER CENTER AT LAKE CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLADNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-474-6190
Mailing Address - Street 1:795 SW STATE ROAD 47
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0453
Mailing Address - Country:US
Mailing Address - Phone:386-758-7822
Mailing Address - Fax:386-758-2224
Practice Address - Street 1:795 SW HIGHWAY 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:386-758-7822
Practice Address - Fax:386-758-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272085000Medicaid
FL74629OtherBCBS
FLDD1689OtherRR MEDICARE
FL272085000Medicaid