Provider Demographics
NPI:1700909488
Name:CENTRAL NEBRASKA RADIATION ONCOLOGY, PC
Entity Type:Organization
Organization Name:CENTRAL NEBRASKA RADIATION ONCOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-398-5450
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:SAINT LIBORY
Mailing Address - State:NE
Mailing Address - Zip Code:68872-0056
Mailing Address - Country:US
Mailing Address - Phone:308-687-6288
Mailing Address - Fax:308-687-6288
Practice Address - Street 1:2116 W FAIDLEY AVE
Practice Address - Street 2:DEPARTMENT OF RADIATION THERAPY
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4645
Practice Address - Country:US
Practice Address - Phone:308-398-5450
Practice Address - Fax:308-398-5351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE187732085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099393Medicare ID - Type UnspecifiedCENTRAL NEBRASKA RADIATIO