Healthcare Provider Details

I. General information

NPI: 1295941516
Provider Name (Legal Business Name): SOUTHSIDE RADIATION ONCOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 HOSPITAL DR MEMORIAL HOSPITAL
MARTINSVILLE VA
24112-1900
US

IV. Provider business mailing address

PO BOX 13624
GREENSBORO NC
27415-3624
US

V. Phone/Fax

Practice location:
  • Phone: 276-666-7200
  • Fax:
Mailing address:
  • Phone: 336-274-4285
  • Fax: 336-274-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number0101032577
License Number StateVA

VIII. Authorized Official

Name: HEATHER WILLIAMS
Title or Position: BILLING SPECIALIST
Credential:
Phone: 336-378-0076