Basic Information
Provider Information | |||||||||
NPI: | 1467764092 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMPIRE ONCOLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 ROSECRANS AVE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | MANHATTAN BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 902663763 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3104168956 | ||||||||
FaxNumber: | 3103354098 | ||||||||
Practice Location | |||||||||
Address1: | 44274 GEORGE CUSHMAN CT | ||||||||
Address2: | SUITE 110 | ||||||||
City: | TEMECULA | ||||||||
State: | CA | ||||||||
PostalCode: | 925925945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9512529300 | ||||||||
FaxNumber: | 9513031800 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2010 | ||||||||
LastUpdateDate: | 07/12/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOTNICK | ||||||||
AuthorizedOfficialFirstName: | LESLIE | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CMO | ||||||||
AuthorizedOfficialTelephone: | 3103354000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
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.