1467672873 NPI number — SOUTH ATLANTIC RADIATION ONCOLOGY, LLC

Table of content: (NPI 1467672873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467672873 NPI number — SOUTH ATLANTIC RADIATION ONCOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH ATLANTIC RADIATION ONCOLOGY, LLC
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:
1467672873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3245
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28406-0245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-251-1839
Provider Business Mailing Address Fax Number:
910-251-8286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
545 OCEAN HIGHWAY WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUPPLY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-754-4716
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAPAGIKOS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
ALEX
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
910-662-8440

Provider Taxonomy Codes

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

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

  • Identifier: 019PH . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5908919 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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