Provider Demographics
NPI:1083604334
Name:CENTRAL GEORGIA RADIATION ONCOLOGY CENTER
Entity Type:Organization
Organization Name:CENTRAL GEORGIA RADIATION ONCOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-743-3466
Mailing Address - Street 1:PO BOX 2464
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2464
Mailing Address - Country:US
Mailing Address - Phone:478-742-2997
Mailing Address - Fax:
Practice Address - Street 1:800 1ST ST
Practice Address - Street 2:SUITE 110
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8300
Practice Address - Country:US
Practice Address - Phone:478-743-3466
Practice Address - Fax:478-746-2049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300025310Medicaid
GAGRP797Medicare PIN