=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356412035
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PORT RADIATION THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 N COUNTRY RD
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-476-2757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 N COUNTRY RD
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-476-2757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | EDWARD H GLENN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 631-476-2757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------