Basic Information
| Provider Information | |||||||||
| NPI: | 1891086096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIATION THERAPY ASSOCIATES OF WESTERN NORTH CAROLINA, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FOOTHILLS UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 COLONIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 TRYON RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RUTHERFORDTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281393099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282861445 | ||||||||
| FaxNumber: | 8282861443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2011 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/11/2019 | ||||||||
| NPIReactivationDate: | 07/19/2019 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHAFMAN | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4014562690 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.