1114018470 NPI number — SPARTANBURG RADIATION ONCOLOGY ASSOCIATES, PA

Table of content: (NPI 1114018470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114018470 NPI number — SPARTANBURG RADIATION ONCOLOGY ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPARTANBURG RADIATION ONCOLOGY ASSOCIATES, PA
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:
1114018470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 REMITTANCE DR
Provider Second Line Business Mailing Address:
STE 6588
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60675-1001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 EAST WOOD STREET
Provider Second Line Business Practice Location Address:
RADIATION ONCOLOGY
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29303-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-560-6917
Provider Business Practice Location Address Fax Number:
864-560-6014
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOSEY
Authorized Official First Name:
JULIAN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT, CEO
Authorized Official Telephone Number:
864-560-6917

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: 890124V , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP0371 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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