Provider Demographics
NPI:1700884202
Name:NORTHERN BOULEVARD RADIATION ONCOLOGY LLP
Entity Type:Organization
Organization Name:NORTHERN BOULEVARD RADIATION ONCOLOGY LLP
Other - Org Name:NEW YORK ONCOLOGY ASSOC. LLP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ENGRACIO
Authorized Official - Middle Name:C
Authorized Official - Last Name:SAMALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-445-3700
Mailing Address - Street 1:15806 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1641
Mailing Address - Country:US
Mailing Address - Phone:718-445-3700
Mailing Address - Fax:
Practice Address - Street 1:15806 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1641
Practice Address - Country:US
Practice Address - Phone:718-445-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0701494OtherAETNA U.S. HEALTHCARE
NY01687214Medicaid
NY135970-A17OtherHEALTHFIRST
NYA1943029OtherOXFORD
NY135970-A17OtherHEALTHFIRST