Basic Information
| Provider Information | |||||||||
| NPI: | 1528332608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOX CHASE CANCER CENTER MEDICAL GROUP, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RADONC ASSOC OF FCCC, MGI | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157282581 | ||||||||
| FaxNumber: | 2152144038 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 COTTMAN AVE | ||||||||
| Address2: | FOX CHASE CANCER CENTER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157282581 | ||||||||
| FaxNumber: | 2152144038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2012 | ||||||||
| LastUpdateDate: | 06/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | WOODARD | ||||||||
| AuthorizedOfficialFirstName: | TONYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2157073911 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1026888280015 | 05 | PA | MEDICAID | 1026888280028 | 05 | PA | MEDICAID | 1026888280036 | 05 | PA | MEDICAID |