1720419955 NPI number — RADIATION THERAPY ASSOCIATES OF WESTERN NORTH CAROLINA PA

Table of content: (NPI 1720419955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720419955 NPI number — RADIATION THERAPY ASSOCIATES OF WESTERN NORTH CAROLINA PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIATION THERAPY ASSOCIATES OF WESTERN NORTH CAROLINA 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:
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:
1720419955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/11/2019
NPI Reactivation Date:
07/19/2019

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:
600 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
CLYDE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28721-8046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-456-7226
Provider Business Practice Location Address Fax Number:
828-456-7274
Provider Enumeration Date:
12/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SHAFMAN
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
401-456-2690

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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