MEDICARE: THE MEDICAL ONCOLOGY GROUP

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	174400000X	Specialist

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	:	1639155088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MEDICAL ONCOLOGY GROUP

Provider Business Mailing Address
First Line	:	PO BOX 1210
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39502-1210
Country	:	US
Telephone Number	:	228-575-1234
Fax Number	:	228-575-1240

Provider Business Practice Location Address
First Line	:	1340 BROAD AVE
Second Line	:	SUITE 270
City	:	GULFPORT
State	:	MS
Zip	:	39501-2404
Country	:	US
Telephone Number	:	228-575-1234
Fax Number	:	228-575-1240

Authorized Official
Title or Position	:	SENIOR PARTNER/PHYSICIAN
Name	:	EDWIN M DAVIDSON
Credential	:	MD
Telephone Number	:	228-575-1234

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	09/16/2010

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Directions to “THE MEDICAL ONCOLOGY GROUP ” Practice Location

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