Provider Demographics
NPI:1497752729
Name:CENTER FOR RADIATION ONCOLOGY OF TAMPA BAY IN
Entity Type:Organization
Organization Name:CENTER FOR RADIATION ONCOLOGY OF TAMPA BAY IN
Other - Org Name:CENTER FOR RADIATION ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP INDIANA AND SOUTH FLORIDA OPERAI
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, FACHE
Authorized Official - Phone:813-662-6024
Mailing Address - Street 1:2715 WEST VIRGINIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6327
Mailing Address - Country:US
Mailing Address - Phone:813-662-6024
Mailing Address - Fax:813-514-1257
Practice Address - Street 1:717 W ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4921
Practice Address - Country:US
Practice Address - Phone:813-661-6339
Practice Address - Fax:813-661-6442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL270912085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264462200Medicaid
FL264462200Medicaid
FLK1946Medicare PIN