Basic Information
| Provider Information | |||||||||
| NPI: | 1700916848 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETHESDA RESOURCES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BETHESDA CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 W LOUISE AVE | ||||||||
| Address2: | |||||||||
| City: | MUSCLE SHOALS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356611517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563833325 | ||||||||
| FaxNumber: | 2563835911 | ||||||||
| Practice Location | |||||||||
| Address1: | 1124 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638015046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734711765 | ||||||||
| FaxNumber: | 5734714465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 11/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | WEEKS | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2563833325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 2006019883 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.