=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801277470
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY CANCER CENTERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2015
-----------------------------------------------------
Last Update Date | 06/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10967 ALLISONVILLE RD STE 220
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46038-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-663-0577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10967 ALLISONVILLE RD STE 220
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46038-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-663-0577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | PHILLIP FREEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-670-6590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QX0200X
-----------------------------------------------------
Taxonomy Name | Oncology Clinic/Center
-----------------------------------------------------
License Number | 01018102A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------