Basic Information
| Provider Information | |||||||||
| NPI: | 1982619680 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONG BEACH RADIATION ONCOLOGY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 ELM AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624926695 | ||||||||
| FaxNumber: | 5629880389 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629330300 | ||||||||
| FaxNumber: | 5629330301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ZIAULLA | ||||||||
| AuthorizedOfficialFirstName: | SYED | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5624926695 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0047850 | 05 | CA | MEDICAID | ZZZ96707Z | 01 | BLUE SHIELD | OTHER |