Basic Information
| Provider Information | |||||||||
| NPI: | 1700884202 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHERN BOULEVARD RADIATION ONCOLOGY LLP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW YORK ONCOLOGY ASSOC. LLP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15806 NORTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113581641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184453700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15806 NORTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113581641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184453700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | SAMALA | ||||||||
| AuthorizedOfficialFirstName: | ENGRACIO | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7184453700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 0701494 | 01 | NY | AETNA U.S. HEALTHCARE | OTHER | 01687214 | 05 | NY | MEDICAID | 135970-A17 | 01 | NY | HEALTHFIRST | OTHER | A1943029 | 01 | NY | OXFORD | OTHER |