Healthcare Provider Details

I. General information

NPI: 1053315093
Provider Name (Legal Business Name): CAROLINA RADIATION MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W H SMITH BLVD
GREENVILLE NC
27834-3764
US

IV. Provider business mailing address

801 W H SMITH BLVD
GREENVILLE NC
27834-3764
US

V. Phone/Fax

Practice location:
  • Phone: 252-329-0025
  • Fax: 252-329-0325
Mailing address:
  • Phone: 252-329-0025
  • Fax: 252-329-0325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GORDON GARY KOLTIS
Title or Position: PRESIDENT
Credential: MD
Phone: 252-329-0025