Healthcare Provider Details

I. General information

NPI: 1407862899
Provider Name (Legal Business Name): FAMILY CANCER CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 SOUTHCREST CIR SUITE 101
SOUTHAVEN MS
38671-4848
US

IV. Provider business mailing address

P.O. BOX 5111
MEMPHIS TN
38101-5111
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-0755
  • Fax: 662-349-0356
Mailing address:
  • Phone: 901-685-5655
  • Fax: 901-685-2590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number19652
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number18137
License Number StateMS

VIII. Authorized Official

Name: WILLIAM K WALSH
Title or Position: MANAGING PHYSICIAN
Credential: M.D.
Phone: 901-685-5655