Provider Demographics
NPI:1508865684
Name:ONCOLOGY MEDICAL CENTER PC
Entity Type:Organization
Organization Name:ONCOLOGY MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-265-1212
Mailing Address - Street 1:3226 G HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4251
Mailing Address - Country:US
Mailing Address - Phone:912-265-1212
Mailing Address - Fax:912-265-2859
Practice Address - Street 1:3226 G HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4251
Practice Address - Country:US
Practice Address - Phone:912-265-1212
Practice Address - Fax:912-265-2859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015631207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000069297AMedicaid
GA0703820001Medicare NSC
GA000069297AMedicaid
GA295421147AMedicare ID - Type Unspecified