Basic Information
| Provider Information | |||||||||
| NPI: | 1801227285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL RADIATION ONCOLOGY MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | SADDLEBACK RADIATION ONCOLOGY MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 ELM AVE | ||||||||
| Address2: | 201 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624926695 | ||||||||
| FaxNumber: | 5629880389 | ||||||||
| Practice Location | |||||||||
| Address1: | 24953 PASEO DE VALENCIA | ||||||||
| Address2: | |||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926534342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624926695 | ||||||||
| FaxNumber: | 5629880389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2013 | ||||||||
| LastUpdateDate: | 12/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | PUTHAWALA | ||||||||
| AuthorizedOfficialFirstName: | AJMEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5624926695 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
No ID Information.