NPIMap

Organization Active NPI

Port Radiation Therapy PC

  • Diagnostic Radiology Physician
  • Port Jefferson, NY
National Provider Identifier
1356412035
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
PORT RADIATION THERAPY PC
Practice address
75 N Country Rd
Port Jefferson, NY 11777
Phone
(631) 476-2757
NPI assigned
Nov 13, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Edward H Glenn, MDNPI 1922010776
Title
President
Phone
(631) 476-2757

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X NU Primary

Addresses

Primary practice location

75 N Country Rd
Port Jefferson, NY 11777

Mailing address

75 N Country Rd
Port Jefferson, NY 11777
Phone (631) 476-2757

Other identifiers 1

IdentifierTypeStateIssuer
01643645MedicaidNY

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163376000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1356412035",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "75 N COUNTRY RD",
            "city": "PORT JEFFERSON",
            "state": "NY",
            "postal_code": "11777",
            "telephone_number": "631-476-2757"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "75 N COUNTRY RD",
            "city": "PORT JEFFERSON",
            "state": "NY",
            "postal_code": "11777",
            "telephone_number": "631-476-2757"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORT RADIATION THERAPY PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-13",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "GLENN",
        "authorized_official_first_name": "EDWARD",
        "authorized_official_middle_name": "H",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "631-476-2757",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01643645",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Port Jefferson, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.