Provider Demographics
NPI:1184667826
Name:GREENBRIER VALLEY RADIATION ONCOLOGY, PLLC
Entity Type:Organization
Organization Name:GREENBRIER VALLEY RADIATION ONCOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:GABE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-425-9160
Mailing Address - Street 1:210 NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2136
Mailing Address - Country:US
Mailing Address - Phone:304-425-1960
Mailing Address - Fax:304-487-3514
Practice Address - Street 1:187 SKYLAR DRIVE
Practice Address - Street 2:
Practice Address - City:FAIRLEA
Practice Address - State:WV
Practice Address - Zip Code:24901-9359
Practice Address - Country:US
Practice Address - Phone:304-425-1960
Practice Address - Fax:304-487-3514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0011237000Medicaid
WV9300641Medicare ID - Type UnspecifiedMEDICARE GRP. NUMBER
VACA7646Medicare PIN
WV0011237000Medicaid
VAC08085Medicare PIN