Healthcare Provider Details

I. General information

NPI: 1497752729
Provider Name (Legal Business Name): CENTER FOR RADIATION ONCOLOGY OF TAMPA BAY IN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 W ROBERTSON ST
BRANDON FL
33511-4921
US

IV. Provider business mailing address

2715 WEST VIRGINIA AVENUE
TAMPA FL
33607-6327
US

V. Phone/Fax

Practice location:
  • Phone: 813-661-6339
  • Fax: 813-661-6442
Mailing address:
  • Phone: 813-662-6024
  • Fax: 813-514-1257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number27091
License Number StateFL

VIII. Authorized Official

Name: MR. NICK L HERNANDEZ
Title or Position: VP INDIANA AND SOUTH FLORIDA OPERAI
Credential: MBA, FACHE
Phone: 813-662-6024