Healthcare Provider Details

I. General information

NPI: 1174858039
Provider Name (Legal Business Name): PREMIER RADIATION ONCOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 1ST AVE
HUNTINGTON WV
25702-1241
US

IV. Provider business mailing address

PO BOX 1104
RAHWAY NJ
07065-1104
US

V. Phone/Fax

Practice location:
  • Phone: 304-526-1143
  • Fax: 304-526-8942
Mailing address:
  • Phone: 973-444-2664
  • Fax: 732-943-2702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number11879
License Number StateWV

VIII. Authorized Official

Name: DIANE MILLER
Title or Position: BILLING DIRECTOR
Credential:
Phone: 973-444-2664