Basic Information
| Provider Information | |||||||||
| NPI: | 1982832390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA RADIATION ONCOLOGY PL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20085 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336220085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138996226 | ||||||||
| FaxNumber: | 8139858006 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 E. FLETCHER AVE | ||||||||
| Address2: | UCH RADIATION ONCOLOGY DEPARTMENT | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8199716000 | ||||||||
| FaxNumber: | 8139858006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 06/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | NORSOPH | ||||||||
| AuthorizedOfficialFirstName: | ELLIS | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8138996223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0203X | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID |