1629019534 NPI number — THERAPEUTIC RADIATION ONCOLOGY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629019534 NPI number — THERAPEUTIC RADIATION ONCOLOGY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPEUTIC RADIATION ONCOLOGY, PC
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:
1629019534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 PROFESSIONAL CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30274-2531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-907-0554
Provider Business Mailing Address Fax Number:
770-907-9048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1255 HIGHWAY 54 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-4526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-719-5850
Provider Business Practice Location Address Fax Number:
770-719-5849
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMPAGNE
Authorized Official First Name:
NELDA
Authorized Official Middle Name:
H
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
770-907-0554

Provider Taxonomy Codes

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

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

  • Identifier: 300021609A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1629019534 . This is a "NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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