Provider Demographics
NPI:1023282456
Name:JACKSONVILLE RADIATION THERAPY SERVICES LLC
Entity type:Organization
Organization Name:JACKSONVILLE RADIATION THERAPY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOSORETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-931-7275
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7212
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:7751 BAYMEADOWS ROAD E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-645-5045
Practice Address - Fax:904-645-5856
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIATION THERAPY SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-16
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN8404OtherRAILROAD MEDICARE
FLAK201Medicare PIN