Provider Demographics
NPI:1427099290
Name:CARSON TAHOE RADIATION ONCOLOGY
Entity type:Organization
Organization Name:CARSON TAHOE RADIATION ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:REBIDEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-883-5505
Mailing Address - Street 1:1535 MEDICAL PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-4637
Mailing Address - Country:US
Mailing Address - Phone:775-883-5505
Mailing Address - Fax:775-883-6779
Practice Address - Street 1:1535 MEDICAL PARKWAY
Practice Address - Street 2:SUITE A
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4634
Practice Address - Country:US
Practice Address - Phone:775-883-5505
Practice Address - Fax:775-883-6779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100502237Medicaid
NVV35678OtherMEDICARE PTAN