Provider Demographics
NPI:1265541049
Name:EASTGATE RADIATION ONCOLOGY LLC
Entity type:Organization
Organization Name:EASTGATE RADIATION ONCOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALVARJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-335-4056
Mailing Address - Street 1:PO BOX 10050
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90267-7550
Mailing Address - Country:US
Mailing Address - Phone:310-335-4056
Mailing Address - Fax:310-335-4098
Practice Address - Street 1:4415 AICHOLTZ RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1506
Practice Address - Country:US
Practice Address - Phone:513-752-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2675038Medicaid
OHDF8293OtherRAILROAD MEDICARE
OH2675038Medicaid