=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790790715
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CANCER CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2006
-----------------------------------------------------
Last Update Date | 03/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 WILKINSON DR
-----------------------------------------------------
City | DYERSBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38024-2085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-379-0703
-----------------------------------------------------
Fax | 901-379-0532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 5111
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38101-5111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-685-5655
-----------------------------------------------------
Fax | 901-685-2590
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PHYSICIAN
-----------------------------------------------------
Name | WILLIAM K WALKSH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 901-685-5655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 015925
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | MD0000015925
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------