Basic Information
| Provider Information | |||||||||
| NPI: | 1902878143 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIATION ONCOLOGY CENTRAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78399 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631788399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
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| Practice Location | |||||||||
| Address1: | DEPT OF RADIATION ONCOLOGY | ||||||||
| Address2: | 1000 W 10TH STREET | ||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733643205 | ||||||||
| FaxNumber: | 5733642341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 03/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | GRAHAM | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5733643205 | ||||||||
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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 | R3M43 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 208279513 | 05 | MO | MEDICAID |