Basic Information
| Provider Information | |||||||||
| NPI: | 1245633122 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VANTAGE CANCER CARE NETWORK OF INDIANA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROSECRANS AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902663763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103354000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8902 N MERIDIAN ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462605382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178534500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2014 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | UDICIOUS | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 6105190550 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VANTAGE CANCER CARE NETWORKS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ESQUIRE | ||||||||
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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 | 207RX0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No ID Information.