Provider Demographics
NPI:1174613830
Name:VICKSBURG ONCOLOGY ASSOCIATES LLC
Entity type:Organization
Organization Name:VICKSBURG ONCOLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZACHOW
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:601-638-3005
Mailing Address - Street 1:PO BOX 4997
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4997
Mailing Address - Country:US
Mailing Address - Phone:601-362-0600
Mailing Address - Fax:601-638-3227
Practice Address - Street 1:970 LAKELAND DR STE 34
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4640
Practice Address - Country:US
Practice Address - Phone:601-362-0600
Practice Address - Fax:601-638-3227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014095Medicaid
LA1961817Medicaid
MS91-066632OtherBLUE CROSS ACH
LA1961825Medicaid
LA1944653Medicaid
MSC02065Medicare PIN
MS91-066632OtherBLUE CROSS ACH