Provider Demographics
NPI:1548487804
Name:RADIATION ONCOLOGY ASSOCIATES A MEDICAL CORPORATION
Entity type:Organization
Organization Name:RADIATION ONCOLOGY ASSOCIATES A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:EBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-222-1149
Mailing Address - Street 1:1800 BUCKNER ST
Mailing Address - Street 2:SUITE B100
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4440
Mailing Address - Country:US
Mailing Address - Phone:318-222-1149
Mailing Address - Fax:318-425-2335
Practice Address - Street 1:1 SAINT MARY PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4343
Practice Address - Country:US
Practice Address - Phone:318-681-4126
Practice Address - Fax:318-425-2335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08279R2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1927911Medicaid
LA57520Medicare UPIN