Provider Demographics
NPI:1124119052
Name:ONSLOW ONCOLOGY PRACTICE PC
Entity type:Organization
Organization Name:ONSLOW ONCOLOGY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ADESOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:AWOMOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-455-5511
Mailing Address - Street 1:PO BOX 12234
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-2234
Mailing Address - Country:US
Mailing Address - Phone:910-455-5511
Mailing Address - Fax:910-455-4919
Practice Address - Street 1:221 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6333
Practice Address - Country:US
Practice Address - Phone:910-455-5511
Practice Address - Fax:910-455-4919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2010-02-04
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-08
Provider Licenses
StateLicense IDTaxonomies
NC200101004174400000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1292UOtherBLUE CROSS & BLUE SHIELD
NC2292263COtherINDIVIDUAL MEDICARE PIN
NC891292UMedicaid
NC2330507Medicare PIN
NC2292263COtherINDIVIDUAL MEDICARE PIN
NCG78434Medicare UPIN