1467516773 NPI number — NORTHEAST REGIONAL RADIATION ONCOLOGY NETWORK INC

Table of content: (NPI 1467516773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467516773 NPI number — NORTHEAST REGIONAL RADIATION ONCOLOGY NETWORK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST REGIONAL RADIATION ONCOLOGY NETWORK INC
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:
6
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:
1467516773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2864 JOHNSON FERRY RD
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30062-8345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-693-2622
Provider Business Mailing Address Fax Number:
770-693-5821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 HAYNES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06040-4113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-533-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DELGALLO
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
860-646-1222

Provider Taxonomy Codes

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

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

  • Identifier: 004214293 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33006856 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 61426856 . This is a "SAGA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2139370 . This is a "AETNA MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: A1725354 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2158621 . This is a "AETNA USHC" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 954221 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 68RDONC01CT1 . This is a "ANTHEM BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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