Provider Demographics
NPI:1780923151
Name:CENTRAL FLORIDA CANCER INSTITUTE PA
Entity type:Organization
Organization Name:CENTRAL FLORIDA CANCER INSTITUTE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-566-9899
Mailing Address - Street 1:1420 CELEBRATION BLVD
Mailing Address - Street 2:308
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5159
Mailing Address - Country:US
Mailing Address - Phone:407-566-9899
Mailing Address - Fax:407-566-9893
Practice Address - Street 1:2 STATE ROAD 60 W
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4118
Practice Address - Country:US
Practice Address - Phone:863-679-2960
Practice Address - Fax:863-679-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51222261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263977700Medicaid
FLK1475Medicare PIN