Provider Demographics
NPI:1629001045
Name:TEMPLE CANCER CLINIC, PA
Entity type:Organization
Organization Name:TEMPLE CANCER CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANI
Authorized Official - Middle Name:
Authorized Official - Last Name:SUBRAMANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-526-5353
Mailing Address - Street 1:2207 S CLEAR CREEK RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4132
Mailing Address - Country:US
Mailing Address - Phone:254-526-5353
Mailing Address - Fax:254-554-5298
Practice Address - Street 1:2207 S CLEAR CREEK RD
Practice Address - Street 2:SUITE 302
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4132
Practice Address - Country:US
Practice Address - Phone:254-526-5353
Practice Address - Fax:254-554-5298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4724207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1281644-01Medicaid
TX180221701Medicaid
TX8S4240OtherBCBSTX PROVIDER NUMBER
TX180220901Medicaid
TX8F0801Medicare PIN
TX8S4240OtherBCBSTX PROVIDER NUMBER
TX1281644-01Medicaid