| Name | Value |
|---|---|
| PROVIDER TYPE | Allopathic & Osteopathic Physicians |
| CLASSIFICATION | Radiology |
| AREA OF SPECIALIZATION | Therapeutic Radiology |
| STATUS | Active |
| VA CODE | V183009 |
| X12 CODE | 2085R0203X |
| SPECIALTY CODE | 30 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252078 |
| EFFECTIVE DATE/TIME |
|