Provider Demographics
NPI:1386832129
Name:EASTERN SHORE RADIATION ONCOLOGY ASSOC., P.A.
Entity type:Organization
Organization Name:EASTERN SHORE RADIATION ONCOLOGY ASSOC., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:MASTANDREA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-820-6411
Mailing Address - Street 1:509 IDLEWILD AVE
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3889
Mailing Address - Country:US
Mailing Address - Phone:410-820-6411
Mailing Address - Fax:410-820-4229
Practice Address - Street 1:509 IDLEWILD AVE
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601
Practice Address - Country:US
Practice Address - Phone:410-820-6411
Practice Address - Fax:410-820-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00366442085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD088861300Medicaid
MDA64055Medicare UPIN