Provider Demographics
NPI:1316969207
Name:ST. MARYS RADIATION ONCOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:ST. MARYS RADIATION ONCOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:CURRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-691-5123
Mailing Address - Street 1:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92564-0575
Mailing Address - Country:US
Mailing Address - Phone:951-691-5123
Mailing Address - Fax:951-691-5156
Practice Address - Street 1:1043 ELM AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3271
Practice Address - Country:US
Practice Address - Phone:909-263-0321
Practice Address - Fax:951-691-5156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23750261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0077720Medicaid
CAZZZ5444ZOtherBLUE SHIELD
CAW13975Medicare PIN
CAW13975Medicare PIN