Healthcare Provider Details

I. General information

NPI: 1093174377
Provider Name (Legal Business Name): ACKERMAN CANCER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 KINGSLEY AVE SUITE 903
ORANGE PARK FL
32073-4466
US

IV. Provider business mailing address

10881 SAN JOSE BLVD
JACKSONVILLE FL
32223-6612
US

V. Phone/Fax

Practice location:
  • Phone: 904-644-8353
  • Fax: 904-644-8289
Mailing address:
  • Phone: 904-260-3022
  • Fax: 904-260-3947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME92864
License Number StateFL

VIII. Authorized Official

Name: SCOT ACKERMAN
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 904-880-5522