Provider Demographics
NPI:1568873461
Name:GULF COAST RADIATION ONCOLOGY PROFESSIONAL SERVICES PC
Entity Type:Organization
Organization Name:GULF COAST RADIATION ONCOLOGY PROFESSIONAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED DELEGATE
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-943-1680
Mailing Address - Street 1:PO BOX 102546
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2546
Mailing Address - Country:US
Mailing Address - Phone:251-948-7897
Mailing Address - Fax:
Practice Address - Street 1:1703 N BUNNER ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2229
Practice Address - Country:US
Practice Address - Phone:251-943-1680
Practice Address - Fax:251-943-1683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102G709415Medicare PIN