=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265434039
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINA CANCER SPECIALISTS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2005
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 HOSPITAL DR SUITE 2
-----------------------------------------------------
City | CLYDE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28721-8046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-454-0181
-----------------------------------------------------
Fax | 828-454-0584
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 HOSPITAL DR SUITE 2
-----------------------------------------------------
City | CLYDE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28721-8046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-454-0181
-----------------------------------------------------
Fax | 828-454-0584
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MICHAEL STEVEN HELLER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 828-454-0181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 38973
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------