Healthcare Provider Details

I. General information

NPI: 1114904604
Provider Name (Legal Business Name): SIOUXLAND REGIONAL CANCER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 NEBRASKA ST
SIOUX CITY IA
51101-1733
US

IV. Provider business mailing address

PO BOX 5017
SIOUX CITY IA
51102-5017
US

V. Phone/Fax

Practice location:
  • Phone: 712-252-0088
  • Fax: 712-252-9404
Mailing address:
  • Phone: 712-252-9301
  • Fax: 712-252-9337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MS. KRISTA J MCCULLOUGH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 712-252-9301