=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366958829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RBS EVOLUTION OF OKLAHOMA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2017
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 N FLORENCE AVE STE 191
-----------------------------------------------------
City | CLAREMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74017-3187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-283-4078
-----------------------------------------------------
Fax | 615-296-0952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 207321
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75320-7321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-746-4711
-----------------------------------------------------
Fax | 615-296-0952
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DIANE HEATON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 918-283-4078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------