Provider Demographics
NPI:1215159603
Name:NEW YORK RADIATION ONCOLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:NEW YORK RADIATION ONCOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MEDIAVILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-835-9729
Mailing Address - Street 1:92-02 LIBERTY AVENUE
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417
Mailing Address - Country:US
Mailing Address - Phone:718-835-9729
Mailing Address - Fax:718-925-9817
Practice Address - Street 1:92-02 LIBERTY AVENUE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417
Practice Address - Country:US
Practice Address - Phone:718-835-9729
Practice Address - Fax:718-925-9817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02146674Medicaid
NY02146674Medicaid