Provider Demographics
NPI:1053315093
Name:CAROLINA RADIATION MEDICINE, PA
Entity type:Organization
Organization Name:CAROLINA RADIATION MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:KOLTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-329-0025
Mailing Address - Street 1:801 W H SMITH BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3764
Mailing Address - Country:US
Mailing Address - Phone:252-329-0025
Mailing Address - Fax:252-329-0325
Practice Address - Street 1:801 W H SMITH BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3764
Practice Address - Country:US
Practice Address - Phone:252-329-0025
Practice Address - Fax:252-329-0325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC118170OtherTRICARE
NC24-00059OtherUNITED HEALTHCARE
NC89010SKMedicaid
NC010SKOtherBCBS
NC=========003OtherTRICARE
NC010SKOtherBCBS
NC118170OtherTRICARE
NC89010SKMedicaid