Healthcare Provider Details

I. General information

NPI: 1487739322
Provider Name (Legal Business Name): HUNTINGTON RADIATION ONCOLOGY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S. FAIROAKS AVE SUITE 100
PASADENA CA
91105
US

IV. Provider business mailing address

P.O. BOX 67808
LOS ANGELES CA
90067
US

V. Phone/Fax

Practice location:
  • Phone: 626-397-5149
  • Fax: 626-397-2147
Mailing address:
  • Phone: 310-273-7365
  • Fax: 310-273-7366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA42358
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA42358
License Number StateCA

VIII. Authorized Official

Name: DR. KENNETH M. LAM
Title or Position: PRESIDENT
Credential: MD
Phone: 626-397-5149