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General NPI Number Information
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NPI Number | 1558795161
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Entity Type | Organization
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Legal Business Name | PHOENIX ONCOLOGY LOST PINES PLLC
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Dates
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Enumeration Date | 08/30/2013
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Last Update Date | 08/30/2013
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Provider Practice Location Address
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Address Line | 3107 HIGHWAY 71 E
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City | BASTROP
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State | TX
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Zip | 78602-5158
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Country | US
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Telephone | 512-303-5100
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Fax | 512-303-5106
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Provider Business Mailing Address
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Address Line | 3107 HIGHWAY 71 E
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City | BASTROP
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State | TX
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Zip | 78602-5158
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Country | US
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Telephone | 512-303-5100
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Fax | 512-303-5106
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Authorized Official
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Title or Position | OWNER
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Name | JIMMY MICHAEL KERLEY
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Credential | MD
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Telephone | 512-303-5100
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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 | G3515
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License Number State | TX
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