Basic Information
| Provider Information | |||||||||
| NPI: | 1255329942 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETHESDA RESOURCES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | BETHESDA CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2649 | ||||||||
| Address2: | |||||||||
| City: | MUSCLE SHOALS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356622649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563833325 | ||||||||
| FaxNumber: | 2563835911 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 W LOUISE AVE | ||||||||
| Address2: | |||||||||
| City: | MUSCLE SHOALS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356611517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563833325 | ||||||||
| FaxNumber: | 2563835911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 12/13/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STOKES | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 2563833325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 09015885 | 05 | MS | MEDICAID | 09015886 | 05 | MS | MEDICAID |