1639145279 NPI number — NORTHWEST BALTIMORE RADIATION THERAPY REGIONAL CENTER, LLC

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 1639145279 NPI number — NORTHWEST BALTIMORE RADIATION THERAPY REGIONAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST BALTIMORE RADIATION THERAPY REGIONAL CENTER, 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:
LIFEBRIDGE HEALTH RADIATION ONCOLOGY CENTER AT OWING MILLS
Provider Other Organization Name Type Code:
3
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:
1639145279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 CROSSROADS DR
Provider Second Line Business Practice Location Address:
SUITE110
Provider Business Practice Location Address City Name:
OWINGS MILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21117-5421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-998-9993
Provider Business Practice Location Address Fax Number:
410-998-4242
Provider Enumeration Date:
02/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
N.T.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
239-931-7342

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: CK7262 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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