Basic Information
| Provider Information | |||||||||
| NPI: | 1053373605 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WATERBURY RADIATION ONCOLOGY ASSOCIATES, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WATERBURY RADIATION ONCOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020A E BOAL AVE | ||||||||
| Address2: | |||||||||
| City: | BOALSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168271509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142378627 | ||||||||
| FaxNumber: | 8142380083 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 CHASE PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035755555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BITTERMAN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2035755555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 50WTBYRADCT01 | 01 | CT | ANTHEM BCBS | OTHER | P1007815 | 01 | CT | OXFORD | OTHER | 001201151 | 05 | CT | MEDICAID | OOR3664 | 01 | CT | PHS/HEALTHNET | OTHER |