=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861656308
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WASHINGTON RADIATION ONCOLOGY CENTER, A MEDICAL GROUP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2008
-----------------------------------------------------
Last Update Date | 07/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39101 CIVIC CENTER DR
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-5817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-796-7212
-----------------------------------------------------
Fax | 510-745-6469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39101 CIVIC CENTER DR
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-5817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-796-7212
-----------------------------------------------------
Fax | 510-745-6469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ALBERT L. BROOKS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 510-795-2026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | G36600
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------