Basic Information
| Provider Information | |||||||||
| NPI: | 1942208145 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLESTON RADIATION THERAPY CONSULTANTS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896158 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004514959 | ||||||||
| FaxNumber: | 6027733664 | ||||||||
| Practice Location | |||||||||
| Address1: | 3415 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043881790 | ||||||||
| FaxNumber: | 3043881768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HORTON | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8004514959 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 001 | WV | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0007557000 | 05 | WV | MEDICAID |