Basic Information
| Provider Information | |||||||||
| NPI: | 1326270984 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TYLER TEXAS RADIATION ONCOLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 09-047, PO BOX 9600 | ||||||||
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| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755059600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035312371 | ||||||||
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| Practice Location | |||||||||
| Address1: | 721 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035955550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2009 | ||||||||
| LastUpdateDate: | 08/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS-MCKELLAR | ||||||||
| AuthorizedOfficialFirstName: | HEIDI | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9035955550 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.