1063454783 NPI number — 21ST CENTURY ONCOLOGY OF HARFORD COUNTY MARYLAND, LLC

Table of content: (NPI 1063454783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063454783 NPI number — 21ST CENTURY ONCOLOGY OF HARFORD COUNTY MARYLAND, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
21ST CENTURY ONCOLOGY OF HARFORD COUNTY MARYLAND, 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:
RIVERSIDE ONCOLOGY CENTER
Provider Other Organization Name Type Code:
3
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:
1063454783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 BRASS MILL RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
BELCAMP
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21017-1217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-272-9224
Provider Business Practice Location Address Fax Number:
410-575-7951
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
N.T.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
239-931-7281

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DF4872 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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