Basic Information
| Provider Information | |||||||||
| NPI: | 1265541049 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTGATE RADIATION ONCOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10050 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902677550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103354056 | ||||||||
| FaxNumber: | 3103354098 | ||||||||
| Practice Location | |||||||||
| Address1: | 4415 AICHOLTZ RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452451506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137528100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 07/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | SHALVARJIAN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3103354056 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 2675038 | 05 | OH | MEDICAID | DF8293 | 01 | OH | RAILROAD MEDICARE | OTHER |