Basic Information
| Provider Information | |||||||||
| NPI: | 1841384138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH ALABAMA RADIATION ONCOLOGY, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GULF COAST CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1380 | ||||||||
| Address2: | |||||||||
| City: | FOLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516261755 | ||||||||
| FaxNumber: | 2516261755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1703 N BUNNER ST | ||||||||
| Address2: | |||||||||
| City: | FOLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365352229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516261755 | ||||||||
| FaxNumber: | 2519801683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HIXSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | CARROLL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2519431680 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH ALABAMA RADIATION ONCOLOGY, PC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
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 | 01D1068466 | 01 | AL | CLIA | OTHER | CC3256 | 01 | AL | RR MEDICARE | OTHER | 51524757 | 01 | AL | BCBS | OTHER | 529601710 | 05 | AL | MEDICAID |