Basic Information
Provider Information | |||||||||
NPI: | 1477984466 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEMORIAL RADIATION ONCOLOGY MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 844945 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900844945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624926695 | ||||||||
FaxNumber: | 5629330301 | ||||||||
Practice Location | |||||||||
Address1: | 2801 ATLANTIC AVE | ||||||||
Address2: |   | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908061701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5125832004 | ||||||||
FaxNumber: | 5629330301 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2013 | ||||||||
LastUpdateDate: | 03/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARSOLIA | ||||||||
AuthorizedOfficialFirstName: | ASIF | ||||||||
AuthorizedOfficialMiddleName: | R. | ||||||||
AuthorizedOfficialTitleorPosition: | MD/AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 5624926695 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MEMORIAL RADIATION ONCOLOGY MEDICAL GROUP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 03/09/2020 |
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.