Provider Demographics
NPI:1386791200
Name:THERAPEUTIC RADIOLOGY ASSO, P.A.
Entity type:Organization
Organization Name:THERAPEUTIC RADIOLOGY ASSO, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:CORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-665-4650
Mailing Address - Street 1:11110 MEDICAL CAMPUS RD
Mailing Address - Street 2:SUITE 129
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6700
Mailing Address - Country:US
Mailing Address - Phone:301-665-4650
Mailing Address - Fax:301-665-4648
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 129
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6700
Practice Address - Country:US
Practice Address - Phone:301-665-4650
Practice Address - Fax:301-665-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00395182085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD147891500Medicaid
MD147891500Medicaid
MD005LMedicare ID - Type Unspecified