Provider Demographics
NPI:1750496527
Name:PEACHTREE RADIATION ONCOLOGY SERVICES PC
Entity Type:Organization
Organization Name:PEACHTREE RADIATION ONCOLOGY SERVICES PC
Other - Org Name:RADIATION ONCOLOGY PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:NOWLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:404-605-3319
Mailing Address - Street 1:PO BOX 102543
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2543
Mailing Address - Country:US
Mailing Address - Phone:404-605-3319
Mailing Address - Fax:770-916-4434
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:DEPT OF RADIATION ONCOLOGY
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-605-3319
Practice Address - Fax:770-916-4434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00512828DMedicaid
GA366662326AMedicaid
GA00937076AMedicaid
GA92BDBDZMedicare ID - Type UnspecifiedFREDERICK SCHWAIBOLD
GA92BDDJTMedicare ID - Type UnspecifiedLINDA WOBECK
GAG98440Medicare UPIN
GA00512828DMedicaid
GA=========AMedicare PIN
GA00937076AMedicaid
GA366662326AMedicaid