Basic Information
| Provider Information | |||||||||
| NPI: | 1679199392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN RAD ONC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 809 SOUTH PARK STREET | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788018746 | ||||||||
| FaxNumber: | 6788018746 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 SOUTH PARK STREET | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788018746 | ||||||||
| FaxNumber: | 6788018746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2020 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
| AuthorizedOfficialMiddleName: | ARTHUR | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4047965898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/18/2020 | ||||||||
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.