Provider Demographics
NPI:1730231887
Name:OWENSBORO CANCER CENTER PSC
Entity type:Organization
Organization Name:OWENSBORO CANCER CENTER PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DATTATRAYA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRAJAPATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-688-1900
Mailing Address - Street 1:PO BOX 1784
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42302-1784
Mailing Address - Country:US
Mailing Address - Phone:270-688-1900
Mailing Address - Fax:270-688-1905
Practice Address - Street 1:1020 BRECKENRIDGE ST
Practice Address - Street 2:STE 200
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1784
Practice Address - Country:US
Practice Address - Phone:270-688-1900
Practice Address - Fax:270-688-1905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21298207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000196488OtherANTHEM
KY36564OtherKY LICENSE
KY65946162Medicaid
KY000000027405OtherANTHEM
KY00337Medicare PIN
KY36564OtherKY LICENSE
KY000000027405OtherANTHEM
KY000000196488OtherANTHEM
KYG82216Medicare UPIN