Provider Demographics
NPI:1225258809
Name:RADIATION ONCOLOGY ST MARY PLACE LLC
Entity Type:Organization
Organization Name:RADIATION ONCOLOGY ST MARY PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-222-1149
Mailing Address - Street 1:PO BOX 9600
Mailing Address - Street 2:DEPT 09 042
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ONE SAINT MARY PLACE
Practice Address - Street 2:CANCER TREATMENT CENTER
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4343
Practice Address - Country:US
Practice Address - Phone:318-681-4126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0224042085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CY63Medicare PIN