Provider Demographics
NPI:1740272871
Name:WYOMING VALLEY RADIATION MEDICINE ASSOCIATES P C
Entity type:Organization
Organization Name:WYOMING VALLEY RADIATION MEDICINE ASSOCIATES P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-822-9822
Mailing Address - Street 1:50 ROOSEVELT TER
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-3517
Mailing Address - Country:US
Mailing Address - Phone:570-822-9822
Mailing Address - Fax:570-822-7955
Practice Address - Street 1:50 ROOSEVELT TER
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3517
Practice Address - Country:US
Practice Address - Phone:570-822-9822
Practice Address - Fax:570-822-7955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
PAAC02-40449261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA043873Medicare PIN