Healthcare Provider Details

I. General information

NPI: 1912786963
Provider Name (Legal Business Name): ACKERMAN CANCER CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2023
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 W TWINCOURT TRL STE 701
ST AUGUSTINE FL
32095-8884
US

IV. Provider business mailing address

10881 SAN JOSE BLVD
JACKSONVILLE FL
32223-6612
US

V. Phone/Fax

Practice location:
  • Phone: 904-490-7400
  • Fax:
Mailing address:
  • Phone: 908-880-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

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