MEDICARE: COMPREHENSIVE RADIATION ONCOLOGY, LLC

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	:	1306338090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPREHENSIVE RADIATION ONCOLOGY, LLC

Provider Business Mailing Address
First Line	:	2000 HEALTH PARK DR
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4525
Country	:	US
Telephone Number	:	615-372-5426
Fax Number	:	866-700-8452

Provider Business Practice Location Address
First Line	:	4685 S CONGRESS AVE
Second Line	:
City	:	PALM SPRINGS
State	:	FL
Zip	:	33461-4761
Country	:	US
Telephone Number	:	561-548-2662
Fax Number	:	561-548-1633

Authorized Official
Title or Position	:	GROUP VP/AUTHORIZED OFFICIAL
Name	:	MR. W. TEDERICK JOHNSON
Credential	:
Telephone Number	:	615-372-3375

Provider Enumeration Date	:	05/30/2018
Last Update Date	:	06/14/2021

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