MEDICARE: SOUTHWEST RADIATION ONCOLOGY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician	16840	OK

General Provider Information

NPI Number	:	1023001237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST RADIATION ONCOLOGY, INC

Provider Business Mailing Address
First Line	:	PO BOX 1072
Second Line	:
City	:	NORMAN
State	:	OK
Zip	:	73070-1072
Country	:	US
Telephone Number	:	405-329-2389
Fax Number	:	405-321-0326

Provider Business Practice Location Address
First Line	:	1000 N LEE AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-1036
Country	:	US
Telephone Number	:	405-329-2389
Fax Number	:	405-321-0326

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CLINTON A. MEDBERY
Credential	:	M.D.
Telephone Number	:	405-329-2389

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	05/17/2011

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