1356320972 NPI number — KINGSTON RADIATION ONCOLOGY

Table of content: (NPI 1356320972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356320972 NPI number — KINGSTON RADIATION ONCOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGSTON RADIATION ONCOLOGY
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:
1356320972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1020A E BOAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOALSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16827-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-237-8627
Provider Business Mailing Address Fax Number:
814-238-0083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 MARYS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12401-5852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-339-7700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TAPEN
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
845-339-7700

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  1417055922 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7066 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 527650 . This is a "AETNA USHC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01129868 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39711 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".