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NPI Code Detail

MEDICARE: CENTRAL NEBRASKA RADIATION ONCOLOGY, PC

MEDICARE: CENTRAL NEBRASKA RADIATION ONCOLOGY, PC
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
12085R0001XRadiation Oncology Physician18773NE

General Provider Information

NPI Number : 1700909488
Entity Type Code : Organization
Provider Name (Legal Business Name) : CENTRAL NEBRASKA RADIATION ONCOLOGY, PC
Provider Business Mailing Address
First Line : PO BOX 56
Second Line :
City : SAINT LIBORY
State : NE
Zip : 68872-0056
Country : US
Telephone Number : 308-687-6288
Fax Number : 308-687-6288
Provider Business Practice Location Address
First Line : 2116 W FAIDLEY AVE
Second Line : DEPARTMENT OF RADIATION THERAPY
City : GRAND ISLAND
State : NE
Zip : 68803-4645
Country : US
Telephone Number : 308-398-5450
Fax Number : 308-398-5351
Authorized Official
Title or Position : PRESIDENT
Name : DR. MARK EDWIN BOLTON
Credential : M.D.
Telephone Number : 308-398-5450
Provider Enumeration Date : 04/09/2007
Last Update Date : 08/22/2020

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