Provider Demographics
NPI:1134219108
Name:PIEDMONT RADIATION ONCOLOGY P A
Entity type:Organization
Organization Name:PIEDMONT RADIATION ONCOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:A
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-806-0710
Mailing Address - Street 1:200 QUEENS RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3264
Mailing Address - Country:US
Mailing Address - Phone:336-718-5095
Mailing Address - Fax:336-718-9257
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-8592
Practice Address - Fax:336-718-9269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011GXOtherNC BLUE CROSS BLUE SHIELD
NC89011GXMedicaid
NC89011GXMedicaid
NC2344536Medicare ID - Type UnspecifiedCIGNA MEDICARE