=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588903587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEADOWS REGIONAL CANCER CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2013
-----------------------------------------------------
Last Update Date | 02/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MEADOWS PKWY
-----------------------------------------------------
City | VIDALIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30474-8759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-535-5800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 MEADOWS PKWY
-----------------------------------------------------
City | VIDALIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30474-8759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-535-5800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO - SRPCC
-----------------------------------------------------
Name | MR. TONY MARCUS OSTEEN
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 912-537-9861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------