Provider Demographics
NPI:1003817958
Name:FAYETTE ONCOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:FAYETTE ONCOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT-CANCER SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOGOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-692-2451
Mailing Address - Street 1:2 HOT METAL ST
Mailing Address - Street 2:QUANTUM ONE, N430
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15203-2348
Mailing Address - Country:US
Mailing Address - Phone:412-432-7706
Mailing Address - Fax:412-432-7691
Practice Address - Street 1:51 BREWER DR
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-8400
Practice Address - Country:US
Practice Address - Phone:724-437-2503
Practice Address - Fax:724-437-8846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031860E2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1564200OtherHIGHMARK
PA1008852920001Medicaid
PA1008852920003Medicaid
PA091787OtherPA MEDICARE IDTF
PADB2573Medicare PIN
PA076125SEHMedicare PIN