Provider Demographics
NPI:1780724690
Name:NORTH CAROLINA RADIATION ONCOLOGY AFFILIATES PA
Entity type:Organization
Organization Name:NORTH CAROLINA RADIATION ONCOLOGY AFFILIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHRYSTAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-538-7725
Mailing Address - Street 1:PO BOX 65595
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0595
Mailing Address - Country:US
Mailing Address - Phone:336-538-7725
Mailing Address - Fax:336-538-7785
Practice Address - Street 1:1236 HUFFMAN MILL RD
Practice Address - Street 2:SUITE 120
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-7725
Practice Address - Fax:336-538-7785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7922488Medicaid
NC890123MMedicaid
NC7922488Medicaid