Provider Demographics
NPI:1801812953
Name:CLARK RADIATION ONCOLOGY
Entity type:Organization
Organization Name:CLARK RADIATION ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:VICTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-323-5425
Mailing Address - Street 1:148 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-2547
Mailing Address - Country:US
Mailing Address - Phone:937-323-5425
Mailing Address - Fax:937-323-5495
Practice Address - Street 1:148 W NORTH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2547
Practice Address - Country:US
Practice Address - Phone:937-323-5425
Practice Address - Fax:937-323-5495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9920792OtherMEDICARE GROUP ID