Provider Demographics
NPI:1801227285
Name:MEMORIAL RADIATION ONCOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:MEMORIAL RADIATION ONCOLOGY MEDICAL GROUP
Other - Org Name:SADDLEBACK RADIATION ONCOLOGY MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:AJMEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PUTHAWALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-492-6695
Mailing Address - Street 1:2650 ELM AVE
Mailing Address - Street 2:201
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1651
Mailing Address - Country:US
Mailing Address - Phone:562-492-6695
Mailing Address - Fax:562-988-0389
Practice Address - Street 1:24953 PASEO DE VALENCIA
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4342
Practice Address - Country:US
Practice Address - Phone:562-492-6695
Practice Address - Fax:562-988-0389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty