Healthcare Provider Details

I. General information

NPI: 1326107871
Provider Name (Legal Business Name): MISSOURI CANCER CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 12/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MEDICAL PLAZA SUITE 100
LAKE ST. LOUIS MO
63367
US

IV. Provider business mailing address

1078 WENTZVILLE PARKWAY
WENTZVILLE MO
63385
US

V. Phone/Fax

Practice location:
  • Phone: 636-639-8620
  • Fax: 636-639-8665
Mailing address:
  • Phone: 636-639-8644
  • Fax: 636-639-8665

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 Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: LINDA J VINCENT
Title or Position: ADMINISTRATOR
Credential:
Phone: 636-639-8650