Provider Demographics
NPI:1790721629
Name:RIVERSIDE RADIATION ONCOLOGY INC
Entity Type:Organization
Organization Name:RIVERSIDE RADIATION ONCOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRNKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-566-5000
Mailing Address - Street 1:PO BOX 182039
Mailing Address - Street 2:DEPT 086
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43218-2039
Mailing Address - Country:US
Mailing Address - Phone:614-430-5712
Mailing Address - Fax:
Practice Address - Street 1:3525 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3937
Practice Address - Country:US
Practice Address - Phone:614-566-5000
Practice Address - Fax:614-566-6958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0649436Medicaid
CB5260OtherMEDICARE RAILROAD
OH0649436Medicaid
OH0649436Medicaid
OH9922592Medicare PIN