Basic Information
| Provider Information | |||||||||
| NPI: | 1225274244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE RADIATION ONCOLOGY CENTERS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2084 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462062084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003319294 | ||||||||
| FaxNumber: | 8124719282 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 N BURKHARDT RD | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477152740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124741110 | ||||||||
| FaxNumber: | 8124741303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2008 | ||||||||
| LastUpdateDate: | 10/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | CHANG | ||||||||
| AuthorizedOfficialFirstName: | JOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHAIRPERSON | ||||||||
| AuthorizedOfficialTelephone: | 3103354000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 261QX0203X | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation |
ID Information
| ID | Type | State | Issuer | Description | DP0313 | 01 | IN | RR MEDICARE | OTHER | 200926120B | 05 | IN | MEDICAID | 200926120A | 05 | IN | MEDICAID |