Basic Information
| Provider Information | |||||||||
| NPI: | 1043518905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUEENS MEDICAL RADIOTHERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10050 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902677550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103354000 | ||||||||
| FaxNumber: | 3103354098 | ||||||||
| Practice Location | |||||||||
| Address1: | 15806 NORTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113581641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184453700 | ||||||||
| FaxNumber: | 7184604051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2011 | ||||||||
| LastUpdateDate: | 03/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | BOTNICK | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3103354000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.