Basic Information
| Provider Information | |||||||||
| NPI: | 1316939440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYOMING VALLEY RADIATION MEDICINE SPECIALISTS P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 ROOSEVELT TER | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187023517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708229822 | ||||||||
| FaxNumber: | 5708227955 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 N RIVER ST | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187640999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705521300 | ||||||||
| FaxNumber: | 5705521498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 03/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROSTOCK | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5705521300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0203X | N | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.