Healthcare Provider Details

I. General information

NPI: 1467801985
Provider Name (Legal Business Name): COLLABORATIVE RADIATION ONCOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 KENSINGTON AVE
FLINT MI
48503-2044
US

IV. Provider business mailing address

302 KENSINGTON AVE
FLINT MI
48503-2044
US

V. Phone/Fax

Practice location:
  • Phone: 810-762-8226
  • Fax: 810-762-8016
Mailing address:
  • Phone: 810-762-8226
  • Fax: 810-762-8016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberPK066426
License Number StateMI

VIII. Authorized Official

Name: PAUL GEORGE KOCHERIL
Title or Position: OWNER
Credential: M.D.
Phone: 810-762-8058