Provider Demographics
NPI:1043518905
Name:QUEENS MEDICAL RADIOTHERAPY PC
Entity Type:Organization
Organization Name:QUEENS MEDICAL RADIOTHERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-335-4000
Mailing Address - Street 1:PO BOX 10050
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90267-7550
Mailing Address - Country:US
Mailing Address - Phone:310-335-4000
Mailing Address - Fax:310-335-4098
Practice Address - Street 1:15806 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1641
Practice Address - Country:US
Practice Address - Phone:718-445-3700
Practice Address - Fax:718-460-4051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty