MEDICARE: SOUTH TULSA RT ASSOCIATES 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

General Provider Information

NPI Number	:	1760644587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH TULSA RT ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	11101 HEFNER POINTE DR
Second Line	:	#224
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-5054
Country	:	US
Telephone Number	:	405-418-2200
Fax Number	:	405-418-2201

Provider Business Practice Location Address
First Line	:	2408 E 81ST ST
Second Line	:	STE 110
City	:	TULSA
State	:	OK
Zip	:	74137-4215
Country	:	US
Telephone Number	:	918-388-2300
Fax Number	:	918-388-2301

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. DEREK M PRENTICE
Credential	:
Telephone Number	:	405-418-2200

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	10/07/2008

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