Basic Information
| Provider Information | |||||||||
| NPI: | 1356320972 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGSTON RADIATION ONCOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020A E BOAL AVE | ||||||||
| Address2: | |||||||||
| City: | BOALSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 168271509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142378627 | ||||||||
| FaxNumber: | 8142380083 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 MARYS AVE | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124015852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453397700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 01/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | TAPEN | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8453397700 | ||||||||
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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 | 2085R0001X | 1417055922 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 7066 | 01 | NY | CDPHP | OTHER | 527650 | 01 | NY | AETNA USHC | OTHER | 01129868 | 05 | NY | MEDICAID | 39711 | 01 | NY | MVP | OTHER |