Basic Information
| Provider Information | |||||||||
| NPI: | 1679631329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIATION MEDICINE ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 248856 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731248856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056074520 | ||||||||
| FaxNumber: | 4056074525 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 NW EXPRESSWAY | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731127230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056074520 | ||||||||
| FaxNumber: | 4056074525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | DOH | ||||||||
| AuthorizedOfficialFirstName: | LUCIUS | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4056074520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 100748890A | 05 | OK | MEDICAID | CH9440 | 01 | RAILROAD MEDICARE | OTHER |