Provider Demographics
NPI:1639145279
Name:NORTHWEST BALTIMORE RADIATION THERAPY REGIONAL CENTER, LLC
Entity Type:Organization
Organization Name:NORTHWEST BALTIMORE RADIATION THERAPY REGIONAL CENTER, LLC
Other - Org Name:LIFEBRIDGE HEALTH RADIATION ONCOLOGY CENTER AT OWING MILLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:NT
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-931-7342
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:25 CROSSROADS DR
Practice Address - Street 2:SUITE110
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5421
Practice Address - Country:US
Practice Address - Phone:410-998-9993
Practice Address - Fax:410-998-4242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCK7262OtherRAILROAD MEDICARE
MD516MMedicare PIN