Basic Information
| Provider Information | |||||||||
| NPI: | 1972500841 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTER FOR RADIATION ONCOLOGY OF TAMPA BAY IN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTER FOR RADIATION ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2715 WEST VIRGINIA AVENUE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136626024 | ||||||||
| FaxNumber: | 8135141257 | ||||||||
| Practice Location | |||||||||
| Address1: | 7315 GREEN SLOPE DR | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335411314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137838614 | ||||||||
| FaxNumber: | 8137838538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | NICK | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP INDIANA AND SOUTH FLORIDA OPERAI | ||||||||
| AuthorizedOfficialTelephone: | 8136626024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA, FACHE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 59-3204668 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 264462200 | 05 | FL | MEDICAID |