Provider Demographics
NPI:1447862255
Name:BROAD RIVER ONCOLOGY LLC
Entity type:Organization
Organization Name:BROAD RIVER ONCOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-273-7980
Mailing Address - Street 1:18201 VON KARMAN AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1176
Mailing Address - Country:US
Mailing Address - Phone:800-544-3215
Mailing Address - Fax:
Practice Address - Street 1:122 OKATIE CENTER BLVD N
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-3750
Practice Address - Country:US
Practice Address - Phone:843-273-7980
Practice Address - Fax:843-273-7981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty