Healthcare Provider Details

I. General information

NPI: 1225274244
Provider Name (Legal Business Name): TRI-STATE RADIATION ONCOLOGY CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N BURKHARDT RD
EVANSVILLE IN
47715-2740
US

IV. Provider business mailing address

PO BOX 2084
INDIANAPOLIS IN
46206-2084
US

V. Phone/Fax

Practice location:
  • Phone: 812-474-1110
  • Fax: 812-474-1303
Mailing address:
  • Phone: 800-331-9294
  • Fax: 812-471-9282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOE CHANG
Title or Position: CHAIRPERSON
Credential:
Phone: 310-335-4000