=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124119052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONSLOW ONCOLOGY PRACTICE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 02/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 MEMORIAL DRIVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28546-6333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-455-5511
-----------------------------------------------------
Fax | 910-455-4919
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12234
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28546-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-455-5511
-----------------------------------------------------
Fax | 910-455-4919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | ADESOLA AWOMOLO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 910-455-5511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 200101004
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 200101004
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------