Healthcare Provider Details

I. General information

NPI: 1285655332
Provider Name (Legal Business Name): RADIATION MEDICINE AFFILIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE FLETCHER ALLEN HEALTH CARE, DIV. OF RADIATION ONCOLOGY
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

291 MOODY ST PER SE TECHNOLOGIES
LUDLOW MA
01056-1246
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3506
  • Fax: 802-847-2386
Mailing address:
  • Phone: 800-866-6663
  • Fax: 888-413-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HAROLD JAMES WALLACE III
Title or Position: PRESIDENT
Credential: M.D.
Phone: 802-847-3506