Provider Demographics
NPI:1487739322
Name:HUNTINGTON RADIATION ONCOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:HUNTINGTON RADIATION ONCOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-397-5149
Mailing Address - Street 1:P.O. BOX 67808
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067
Mailing Address - Country:US
Mailing Address - Phone:310-273-7365
Mailing Address - Fax:310-273-7366
Practice Address - Street 1:625 S. FAIROAKS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105
Practice Address - Country:US
Practice Address - Phone:626-397-5149
Practice Address - Fax:626-397-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42358174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE85735Medicare UPIN