1548586035 NPI number — OAK RIDGE RADIATION ONCOLOGY P LLC

Table of content: (NPI 1548586035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548586035 NPI number — OAK RIDGE RADIATION ONCOLOGY P LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAK RIDGE RADIATION ONCOLOGY P 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:
1548586035
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGLER BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32136-0129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-835-4500
Provider Business Mailing Address Fax Number:
865-835-4503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 VERMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK RIDGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37830-6402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-835-4500
Provider Business Practice Location Address Fax Number:
865-835-4503
Provider Enumeration Date:
04/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
NAVO
Authorized Official First Name:
ELLIOT
Authorized Official Middle Name:
BRIN
Authorized Official Title or Position:
AO
Authorized Official Telephone Number:
865-835-4500

Provider Taxonomy Codes

  • Taxonomy code: 2085R0203X , with the licence number:  MD0000025245 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q032005 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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