Provider Demographics
NPI:1629019534
Name:THERAPEUTIC RADIATION ONCOLOGY, PC
Entity Type:Organization
Organization Name:THERAPEUTIC RADIATION ONCOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NELDA
Authorized Official - Middle Name:H
Authorized Official - Last Name:CHAMPAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-907-0554
Mailing Address - Street 1:255 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2531
Mailing Address - Country:US
Mailing Address - Phone:770-907-0554
Mailing Address - Fax:770-907-9048
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:770-719-5850
Practice Address - Fax:770-719-5849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300021609AMedicaid
GA1629019534OtherNPI
GA300021609AMedicaid
GA1629019534OtherNPI