Basic Information
Provider Information | |||||||||
NPI: | 1902852478 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EAST COAST RADIATION ONCOLOGY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020A E BOAL AVE | ||||||||
Address2: |   | ||||||||
City: | BOALSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 168271509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8142378627 | ||||||||
FaxNumber: | 8142380083 | ||||||||
Practice Location | |||||||||
Address1: | 300 2ND AVE | ||||||||
Address2: |   | ||||||||
City: | LONG BRANCH | ||||||||
State: | NJ | ||||||||
PostalCode: | 077406303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7329236890 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEISS | ||||||||
AuthorizedOfficialFirstName: | MITCHELL | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
AuthorizedOfficialTelephone: | 7329236890 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X |   | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 7412703 | 05 | NJ |   | MEDICAID | 0588943 | 01 | NJ | AETNA | OTHER | 1083561 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 0694687000 | 01 | NJ | AMERIHEALTH | OTHER | 9675988 | 01 | NJ | GHI | OTHER |