MEDICARE: AVENUES CANCER CARE INSTITUTE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	ME0043663	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023308806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENUES CANCER CARE INSTITUTE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 57946
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32241-7946
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6144 GAZEBO PARK PL S
Second Line	:	SUITE 211
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-1099
Country	:	US
Telephone Number	:	904-651-9895
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. CARLOS A. OTEYZA
Credential	:	M.D.
Telephone Number	:	904-551-3122

Provider Enumeration Date	:	04/13/2011
Last Update Date	:	03/26/2012

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