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General NPI Number Information
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NPI Number | 1548487804
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Entity Type | Organization
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Legal Business Name | RADIATION ONCOLOGY ASSOCIATES A MEDICAL CORPORATION
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1 SAINT MARY PL
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City | SHREVEPORT
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State | LA
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Zip | 71101-4343
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Country | US
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Telephone | 318-681-4126
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Fax | 318-425-2335
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Provider Business Mailing Address
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Address Line | 1800 BUCKNER ST SUITE B100
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City | SHREVEPORT
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State | LA
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Zip | 71101-4440
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Country | US
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Telephone | 318-222-1149
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Fax | 318-425-2335
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | SALLY EBRAHIM
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Credential |
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Telephone | 318-222-1149
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0001X
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Taxonomy Name | Radiation Oncology Physician
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License Number | 08279R
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License Number State | LA
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