Basic Information
| Provider Information | |||||||||
| NPI: | 1780724690 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH CAROLINA RADIATION ONCOLOGY AFFILIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 65595 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282650595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365387725 | ||||||||
| FaxNumber: | 3365387785 | ||||||||
| Practice Location | |||||||||
| Address1: | 1236 HUFFMAN MILL RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365387725 | ||||||||
| FaxNumber: | 3365387785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 09/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHRYSTAL | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3365387725 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 7922488 | 05 | NC | MEDICAID | 890123M | 05 | NC | MEDICAID |