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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