1316969207 NPI number — ST. MARYS RADIATION ONCOLOGY MEDICAL GROUP

Table of content: (NPI 1316969207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316969207 NPI number — ST. MARYS RADIATION ONCOLOGY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. MARYS RADIATION ONCOLOGY MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316969207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 575
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92564-0575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-691-5123
Provider Business Mailing Address Fax Number:
951-691-5156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1043 ELM AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90813-3271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-263-0321
Provider Business Practice Location Address Fax Number:
951-691-5156
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CURRY
Authorized Official First Name:
DEBBY
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNT MANAGER
Authorized Official Telephone Number:
951-691-5123

Provider Taxonomy Codes

  • Taxonomy code: 261QX0203X , with the licence number:  A23750 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0077720 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ5444Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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