Basic Information
| Provider Information | |||||||||
| NPI: | 1306267380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL RADIATION ONCOLOGY MEDICAL GROUOP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844945 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900844945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624926695 | ||||||||
| FaxNumber: | 5629880389 | ||||||||
| Practice Location | |||||||||
| Address1: | 24302 PASEO DE VALENCIA | ||||||||
| Address2: | |||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926533115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494528880 | ||||||||
| FaxNumber: | 9498595980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2013 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARSOLIA | ||||||||
| AuthorizedOfficialFirstName: | ASIF | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5624926695 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.