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Organization
MEMORIAL SOUTHSIDE CANCER CENTER LLC
Active
Organization
MEMORIAL SOUTHSIDE CANCER CENTER LLC
Active
Other names
Memorial Cancer Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LAVELLE HARDIN (CREDENTIALING COORDINATOR)
(615) 344-8203
Entity
Organization
Contact information
Practice address
5742 BOOTH RD, SUITE B, JACKSONVILLE, FL 32207
(904) 636-6911
(904) 636-6330
Mailing address
5742 BOOTH RD, SUITE B, JACKSONVILLE, FL 32207
(904) 636-6911
(904) 636-6330
Taxonomy
Speciality
Code
Description
License number
State
261QX0203X
Radiation Oncology Clinic/Center
Primary
APPLYING
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00389
BCBS OF FL
FL
05
—
277325200
—
FL
01
—
DG1361
RR MEDICARE
FL
Enumeration date
12/12/2006
Last updated
01/27/2010
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