MEDICARE: ST. MARYS RADIATION ONCOLOGY MEDICAL GROUP

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	261QX0203X	Radiation Oncology Clinic/Center	A23750	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	ZZZ5444Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1316969207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARYS RADIATION ONCOLOGY MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 575
Second Line	:
City	:	MURRIETA
State	:	CA
Zip	:	92564-0575
Country	:	US
Telephone Number	:	951-691-5123
Fax Number	:	951-691-5156

Provider Business Practice Location Address
First Line	:	1043 ELM AVE
Second Line	:	SUITE 110
City	:	LONG BEACH
State	:	CA
Zip	:	90813-3271
Country	:	US
Telephone Number	:	909-263-0321
Fax Number	:	951-691-5156

Authorized Official
Title or Position	:	ACCOUNT MANAGER
Name	:	DEBBY CURRY
Credential	:
Telephone Number	:	951-691-5123

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	03/26/2015

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