Basic Information
| Provider Information | |||||||||
| NPI: | 1437102092 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY RADIOTHERAPY ASSOCIATES MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 10050 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902677550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104168956 | ||||||||
| FaxNumber: | 3105369123 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 ROSECRANS AVE | ||||||||
| Address2: | 400 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902663763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103354056 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/06/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOTNICK | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 3103354065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CH4367 | 01 | CA | RR MEDICARE ST. JUDE | OTHER | GR0013797 | 05 | CA | MEDICAID | GR0013798 | 05 | CA | MEDICAID | GR0013792 | 05 | CA | MEDICAID | GR0013793 | 05 | CA | MEDICAID | GR001379A | 05 | CA | MEDICAID | GR0013791 | 05 | CA | MEDICAID | GR0013794 | 05 | CA | MEDICAID | GR0013796 | 05 | CA | MEDICAID | CJ5668 | 01 | CA | RR MEDICARE RIVERSIDE | OTHER | GR001379C | 05 | CA | MEDICAID | GR001379F | 05 | CA | MEDICAID | CR0476 | 01 | CA | RR MEDICARE PSJ | OTHER | GR001379E | 05 | CA | MEDICAID | CP3272 | 01 | CA | RRMEDICARE SJHC | OTHER | DD9966 | 01 | CA | RR MEDICARE EL CENTRO | OTHER | GR0013790 | 05 | CA | MEDICAID | GR0013799 | 05 | CA | MEDICAID | GR001379B | 05 | CA | MEDICAID | GR001379D | 05 | CA | MEDICAID |