Basic Information
| Provider Information | |||||||||
| NPI: | 1518908847 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEWPORT COAST RADIATION ONCOLOGY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21562 | ||||||||
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| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
| FaxNumber: | 9492630473 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE HOAG DRIVE | ||||||||
| Address2: | CANCER CENTER | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926634162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497645528 | ||||||||
| FaxNumber: | 9497648106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | HAFER | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9497645528 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | G53677 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0203X | G28037 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0001X | A70756 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ60882Z | 01 | CA | BLUE SHIELD OF CA | OTHER | GR0087510 | 05 | CA | MEDICAID |