MEDICARE: EAST BAY RADIATION ONCOLOGY MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255369336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST BAY RADIATION ONCOLOGY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	20126 STANTON AVE STE 101
Second Line	:
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-5270
Country	:	US
Telephone Number	:	510-581-0556
Fax Number	:	510-581-2161

Provider Business Practice Location Address
First Line	:	20126 STANTON AVE STE 101
Second Line	:
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-5270
Country	:	US
Telephone Number	:	510-581-0556
Fax Number	:	510-581-2161

Authorized Official
Title or Position	:	SECRETARY
Name	:	DR. CARL CRAIG VAN WEY
Credential	:	M.D.
Telephone Number	:	510-581-0556

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	08/22/2020

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