voided matls licensing action for racine medical clinic. … · 2020. 5. 19. · s ' |* s (for...
TRANSCRIPT
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V010 SHEET
TO: License fee P.anagement Eranen
7!MFROM:
SUBJECT: VOIDED APPLICATION
Control Number: 7M90-
N 4 n t / / - M /'N l v AApplicant:
////S 71Date Voided:
Reason for Void:
}Jieh-|$6',onnt t.k(>: n:HL ):fAJD.-|-r ~(- -Q9e C n\ %f u //))'?>;p s yd ,-
(mrtreit-m) - H i t _ur
I k" s un b t ? n e rh >> Wo0 fhv dlAnd,,v -
$4'Cb 11 7~
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fignature date
// ''/ )tAttachment: 2. -Of ficial Recoro Copy of''oided Action ;3.
-
FOR LFMS USE ONLY t}o-Final Review of VOID Completed:E
/*Refund Authorized and ; 9cessec- g
No Refund Oue gj h [ dg h h j 1[i "'
}
./O Fee Exempt or Fee hot Requirec ,
i
1"10029 y ',Coments: Log completed - .
Processec by: Y -,
J U )9212230114 921110
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.PDR ADOCK 03018222 |
.C PDR_ . _ _ _ _ _ . . _ . _ _ . - _-_
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|* s (FOR LFMS USE1 .6 I INFORMATION FROM LTS-
| BETWEEN:,
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ILICENSE FEE MANAGEMENT ERANCH, ARM PROCRAM CODE 02120
AND STATUS CODE 0REC 10NAL LICENSING SECTIONS FEE CATECORY: 7C
EXP. DATE: 19931130
! Dh 0 A SUR~REGDT~R~~~~~~~~~~~~:::::::::::::::::::::::::::::::::::::
LICENSE FEE TRANSMITTAL
A. REC 10N
1. APPLICATION ATTACHEDAPPLICANT /LICENEEE RACINE MEDICAL CLINICRECEIVED DATE: 920914DOCKET NO: 3018222CONTROL NO. 393990LICENSE NO. 48-20303-01ACTION TYPE: AMENDMENT
FEE ATTACHED j;/612 g2.
AMOUNT: ,y ;-CHECK NO. ,, scf
3. Cf 9'NTS
!!iE'"::ES:$:$$::::::: ,
S.LICENSEFEEMANAGEMENTBRANCHjCHECKWHENHILESTONE03ISENTLRED/[,/[
1. FEE CATECORY AND AMOVNT: ,2[ '_ , ,,, ,,,,, , , , ,, , , , ,, ,,, , , ,, bf 0,
gggNT ,,,,,J,.fPLICATIONMAYBEPROCESSEDFOR2. CORRECT FEE PAID. A
......
LICENSE [",[[~~~~~~~3. OTHER ........... ......... ............ ._
,
..............................j. ;E. .,
kW ']N'
SIGNED. . . .. .. . . . . . . . . .. ... ::7.U.?;g/h
i
DATE
RECEIVED
SEP 21 1992
REQON Ifl '
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< '(FDR USE)
f A '. :
\/ INFORMAT FROM LTS------~--------
| BETWEEN: "i:
LICENSE FEE MANAGEMENT BRANCH, ARM : PROGRAM CODE 02120STATUS CODE: 0 >
AND : FEE CATECORY: 7Cn R:.10NAL LICENSING EECil0NS EIP. DATE: 19931130-
b0 UR*REEDT~R~~ ~ ~ ~ ~ ~::::::: e;::::::::::::::::::::::::::::*'
eLICENSE FEE TRANSMITTAL
to A. RECION~~ '
1. APPL CATION ATTACHEDAPPL . CANT / LICENSEE: RACINE MEDICAL CLINIC i
RECE;VED DATE: 920914DOCKET NO: 3016222,
CGNTROL NO. 393990I LICENSE NO.: 48-20303-01 umas
ACTION TYPE: AMENDMENT
0FEEATTACHEDIfy,C.',,2.AMOUNT'
CHECK NO. .,4,xp.Z~<p
3. COMMENTS
81CNED ~~ 0 N N {dDATE ~2E~fi~ m ........**
; . '
B. LICENSE FEE MANAGEMENT' BRANCH (CHECK WHEN MILESTONE 03 IS ENTERED /.;/)
I 1. FEE CATECORY AND AMOUNT: ................. ........... ...........2. CORRECT FEE PAID. APPLICATION MAY BE PROCESSED FOR:
AMENDMENT(_3, y
. - - . . . . . - . . .
LtCENSE [~ ~. ~ ~ ~,~.~ ~
g 3. OTHER ........ ................ . . ..
SICNED ,,,,,. ......................... .DATE ..... ............. ... . .
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y ''hy Florida, 33063.
If you have any questions with regard to this application for| gggy ammendment, please feel free to contact me at (414)-631-8131.
D N/[1Lc_,,,,, cm.,maw wnWM Sincerely,
ch*ft/EoE gaA.Racine Medical Clinic
.w7 s ing smet Diane M. Johnson, R.T.NSEP 1 4 1992.| n
P.o. tka msmi - Director of Radiology,ggciogggin.ene. ~ .s - sm1
(uq et son DJ/1m pgEnc 1. $$ $ :: 5 3QQQ'*-
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RACINE,
MIDK'Al CLINK
O(%r
_ Ok .lf [g9September 3, 1992 f: .
-?
Hewitter j~ - -~~ -<
CI,rck tto| G$U/S --~ ~- ..
9 aunt. . flee category f/C g7pr- --- ---
<._.4..,...
U.S. Nuclear Regulatory Commission| L TC.. ",.N k u Region 11] DPD of Feo i pdy-h
,
Date Check nt.c.j,gf(,gjy- -r i ... ,.u"~"
799 Roosevelt Road-
' Date Cornpktod~
Udf1 Glen Ellyn, IL 60137 ^ ~ ' - -WL"|%%" Dys . . pp .
~ ~ ~ ~ - - - - "PT*i;"'tfuT,a c To Whom It May Concern:1 N V E n ?!
b.'.5$$Iu n. u The Racine Medical Clinic is requesting an ammendment to theu uu.-"a n license for Nuclear Medicine. The license number of the facilityP|"s% ii'na.c is 48-20303-01. The docket reference number is 030-18222.% n.._ . ,.s.mn u m.4 u n.s e The fee for ammendment, $460.00, is enclosed.MT .'07m'.%t ~ggy, , n The requested ammendment is regarding condition number 12. The
addition of three physicians as authorized users are:m ,% s_a u.+ ,
Wscluhu1. James A. Toniolo, M.D.m., o..a-s w ,
twum..unac 2. Scott W. Gage, M.D.UDE'N/TGf"* ~ 3. David M. Feldman, M.D.W C: LaP'd , tit,$';Eb ac Dr. James A. Toniolo has passed the American Board of Radiologyh ! M,Wl," . s c written exam in October of 1991 and is scheduled to take the oral
exam in November of 1992. A preceptor statement is enclosed.or.im.,. u n
M T7;. T Ji a c
PC~t~m m Dr. Scott W. Gage is certified by the Board of Radiology and haspassed the written exam in October 1991 and has taken and passedr,.u.,,, .
Ih"TJs'e"' the oral exam in June of 1992. A preceptor statement ish"/.%'d NDac enclosed.G2?.!;;,% mge ,gggs c Dr. David M. Feldman is certified in general radiology by the
}| M..r/n"&"-American Board of Radiology in December of 1985. Enclosed arecopies of ammendments to radioactive material license for theo m u.a . xu na et
< d'i.V|d"i"f' following medical organizations to which Dr. Feldman was"
a t u-. u n. c. authorized as a user of radioactive materials:N L unantiTyi3T|+ 1. Humana of Florida, Humana Hospital Bjnnett, 8201 W.
Broward Blvd., Plantation, Florida c3332G~
p" "",," "2. Margate General Hospital, 5850 Mrgate Blvd. .. Margate,
$h;;;>. Florida, 33063. ( Q
[*rn-Mrt2" If you have any questions with regard [dj thi5 application forammendment, please feel free to contact md at (414)-631-8131.c. .,c..u. ,
Sincerely,' OM M/bL'
m =5 ,d,a,m A.q /s,RRCID" FED- . _ .
Ra_me Medwal Chnic
w s nns unt Diane M. Johnson, R.T.NSEP 1 4 1992r s
r n iw el Director of Radiologynmne.wuown mw wi
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Enc 1. Com0L M 93990
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eopuiNtC 313M SUPPLEMENT e U. L NUCLE AR REGULATORY COMMi&510N16 701
PRECEPTOR ST ATEMENT M/
Sapairmoot B nws t to cannteted tv rw arebtentphysic:m's omrotor. I! mort thm one preceptor a rtecessary to dxumentrever eme, obtern a woore to sto armen t frun ed
KEY TO COLUMN CI. AFFilC ANT PHyllCI AN'$ N AMt AND ADO pt $sP t R10N AL P A RflCIP A flON Es40VLD CON 8tif OF:
evtLNaut 1 Swseermed eneminelece of pet ents to determe^e the gutet>tity f or.
-
rad o notote dopsce e ond/or treatneat end reconveendetion twq f ,g j gO m f *a OI CAM i Orn tO rO Idiu. P*'' ted esege.
yt, tat 41 aoOPt54 2Coretowetsom 6m ese tshtestion omd ec1wel admiaistration of doseI
to t*e pet. eat incfwdes Wevtetion of tre tea et<on gone, tetstedj neeseenwats eW piorting of deia,
Mosqaste period of l'e.aeag to enetse phys.t.am eo wereps red:caartidc i TI * ' ~ T s t' Tit i ses ch get eeti and et; oss seteets th'ov9h d.syiusta eas/pr tow ee ofr
, _ % %k 2L 6cm / i ~~'-2. CLINIC AL 171 AINING ANO E XPE RIE NCE OF ABOVE N AME O PHY3|CI AN
NtWBt R OPCA .8 INVOLVING COMM(Ni$
Pt EON AL few,tismat.atonnetton er com/ neats may1501OPL CONDIflONS Ot AGNOsto 04 f pt Af f D
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F ORM NRC 41JM.$vFPLf ME NT S Page 8<
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00Nin a 93990- w . __ _ _ __
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PRECEPTOR STATEMENT (Cmtinued/ -gf_f
2. CLINICAL TRAINING AND EXPERIENCE OF ABOVE N AMED PH' ICI AN (Continued /N'UMEE4 C#
casa s 1NvolvlNG coMMtNisPt W AL ImanW es teernet w eenmea n ain k
ISOTOPE CCNDITIONS DI AONostD OR T98 Af tD P A RTICIP Afl04 sw6= t ed M Ap/<s m an wear ent eee a f
A B C D
P J2 TRE ATMENT OP POLYCYTH{ MI A VER A,13404l LEVKLMI A, AND SONE MtT ASTA$f $
INTR ACAvlTARY T RE ATMENT Q
TRE ATMENT CF THYR 010 C ARCINOM A QTRE ATMENT OF HYPE RTHYRotOI5u 5
Au 198 INTR AC AVIT ARY TRE ATMENT OC OGO INti R$Titl AL TRE ATMENT Q
| C 137 (NTR AC AVIT ARY TRE A TMEN T
! INTER 1Titl AL T RE ATMENT O| ,,. m .
nwo' TELLTHE RAPY TRL ATWENT O,
$, 90 THE ATMENT OF (YE DiSE ASE OR A0 LOPH ARMActVTIC AL P RE P A R A TION O
T[ CE NE R ATOR gg', CENERATOR g
T c-99m Rt AGENT KITS JCOfer
3. DATES AND TOT AL NUMBER OF HOURS RECElVED IN CLINICAL RADIOlSOTOPE TR#iNING
od t uo Au3 l%}hartqq| 6<a pF 194 )
4. THE TRAINING AND EXPERIENCE INDICATED ABOVEa PRECEPTORT, sign ATVnE
WAS OBTAINED UNDER THE SUPERVISION OF:'
a 8Aus or svPs avisoR
omM DeVi5. M.D. ''
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PRECEPTOR STATEMENT N
SupVemmt 8 truss t le icunple trd tv tt4 5'D ,cen t phys c w's procratpr. It mCvs stian tre proctptor ,s nettssary to documentI
repot.once, obtsen a seDstear Jtetrment trcun eachKEY TO COLUMN C
1. APPLIC ANf PHYSICI AN'S N AME AND ACORI ss Pt RSON AL P ARTICIPAflON SHOULO cot 4Eltf OF:
1.$.w.ti.rvm.d . e4 PNn.ta.,i .I ga.,ti.mts to det.tmine th. .w.t.tpiaf y f.,,
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2. CLINICAL TR AINING AND LXPERIENCE OF ABOVE NAMED PHYSICI ANNtmast m OF
C Ast s sNv0LvlNG COdMENTSPT RSON AL lA# tre.I ,n fonn.t,ars a twnmen s mar
IS O T Ce t CONOlflONS DI AGNOstO OR T RE Af t 0 P A RitCiP A ft ON 4. way,,,ts,a,a aw,#,ces,on .rp.i.e eeesJ0
A 9 C
De ACN0515 OF THY ROiO FUNCTION %d [IDDE f t fiMIN Aflott OF OLOOO ANO kOLOOO P LASM A VOLUMF
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_ ' 75 P ANCRt AS IM AGING _hs
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,ORM NRCaiw.sVPPu MlN r .Page 6
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PRECEPTOR STATEMENT (CcvtrinvPd/ -44-g
2. CLINICAL TR AINING AND EXPERIENCE OF ABOVE NAMED PHYSICI AN /Cm!inued)NUMRTRT#
CA$t t lNv0 LVING COMMENT 8180 T OPE CONDiff 0NS DtAGN05t D OR TRE Af tD P f RSON A L I m rteamW m W atum w uam m m m k
P A R TICIP A TION sventeam dupuso en wewere eee tt /
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(Saneh) LturtMI A. ANO 90NE ME T ASTA5E S h,A22 gINT R ACAvlTA RY T Re A >Me ~ T, , , ,
[THE ATMENT OF THYROiQ C ARCINOM A
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C &GO INTE RSTITI AL TRE ATMENT gor
.
CetJ7 INTR AC AvtTARY TRE A TMEN T
INTT R$fifl AL TRE AIMENT hide
o' TT LE THE RAPY THE ATMENr OSe90 TRE ATM(N T OF t YE 015T ASE O
R ADIOPH ARMACEUTICAL PREPA RA T10N
7cN[ GE NE R ATOR h"
g\ GtNERATOR gTc99m Rf AGENT et|TS
Oser
1 DATES AND TOTAL NUMBER'Of HOURS RECEIVED IN CLINICAL RADIOlSOTOPE TRAINING
Fe b 19 9 L
Tune M9L4. THE TRAINING AND EXPERIENCE INDICATED A00Vg IL PRECEPTOR 3 54GN ATURE
WAS OBTAINED UNOER THE SUPERVISION OF:a Naut of surs nvasoR s
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th N Auf QF 4NSTITUTION 7. P fi( CE P TO R'S N 68 Par aw 4pe or p' tint /
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~~June, 25 1992
To whom it may concern:
|| Doctor James Toniolo received four months of Nuclear Medicinetraining under the supervision of Doctor Thomae Davis at MountSinai Hospital . Due to the untimely death of Doctor Davis, I haveshifted our Nuclear Medicine training to Lutheran GeneralHospital under the direction of Doctor Charles Martinez.
The Nuclear Medicine Department here at Mount Sinai is under thejurisdiction of the Department of Medicine. They have met withlimited success at finding a full time replacement for DoctorDavis.
Consequently, Doctor Martinez is presently considered our NuclearMedicine preceptor.
Sincerely,,
o
Alan Hecht, M.D.Chairman and Residency Program DirectorDepartment of Radiology
Comut!a. 93990n
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1ponu NRC 313MSUPPLEMENT A
U.S. NUCLE AR REGULATORY COMMi$$lON' ' *
TRAINING AND EXPERIENCEAUTHORIZED USER OR RADIATION SAFETY OFFICER
t. NAME OF AUTHOR 1210 USE R CM MAOl4 TION SAFETY OFFICER 2. SfATE OR TERRITORY IN |WHICH LICEN$t O TO
d d 6% f *.= IOntof0 All h ,,
3 CERilFICATKW$
SPECI A LYY SO ARD CAT E CORY MONTH ANO Yt AR CERTIFIEDA 9 C1
|
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4. TRAINING HECEIVED IN BA8tc RAD 40tSOTOP'E HANDLING TECHNIQUES
TYPt AND LtNOTH OF TRAINING
LECTURtl SUPE RVI$t OFit L O OP TRAINING LOCATION AND O Att tsl OF T R AINING LASOMATORY LA80RATORYA B COUR$t$ E XPE RIE NCEIHews) (Heds)
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|(3p) ,]cg g , g (h ,'cagg , ho e k b4
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c. MATHEMAtlCS Pt RTAINING TOTHE USE ANO Mf A$UREMENTOF M AOICACYivlTY
& R ADI ATION slOLOGY k
e. M AOIOPHARMActVTICALCH t ul3T R Y g(
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|L EXPERlENCE w|TH R AD1 AT10N. (Actus!vse of Rodbolsotopos or Equivalent Experietwo)ISOTOP E MAXIMUM AMOUNT WHERE EXPERitNCE WAS O AiNEO OUR ATION OF EXPERIENCE TYPE OF UEt
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CURRICULUM, VITAE|
JAMES A. TONIOLO, M.D.
Bpme Addressi Office Addresgl ]
1905 Jacobs Court Racine Radiology Group SC I
Racine, Wisconsin 51403 1803 Spring StreetRacine, Wise nsin 53405 '
414-552-9332414-632-5580
Certification and Licensurql- Diplomate, National Board of Medical Examiners, July, 1989.- Licensed Physician and Surgeon, State of Illinois, July, 1990.- Licensed to practice Medicine and Surgery, State of Wisconsin,
September, 1991.- Passed American Board of Radiology written examination.October, 1991.
EdRoation: L'
- University of Health Sciences /The Chicago Medical School, North'Chicago, Illinois, M.D., 1988.
- Northern Illinois University, DeKalb, Illinois, B.S. , Cum Laude,Biological Sciences, 1982.
P_o31 grad _uate Trainino:Chicago Medical School / Mt. Sinai Hospital Medical Center,Department of Radiology, Chicago, Illinois, July, 1988-present.
Awntds and Honors:Chief Resident, July, 1991-present.
Professiopal Society Memberships and Commiting_f_ppointments:- Radiologic Society of North America, 1988.- American College of Radiology, 1988.- Continuing Medical Education and Library Committee, Mt. Sinai
Hospital, July, 1991-present.- Radiographic Contrast Committee, Mt. Sinai Hospital, October,
1991-present.
Ear _a_onel DatorBirthdate: February 12, 1960 Birthplace: Chicago, IllinoisMarital Status: Married Wife: Ann Children: Katie
Rgsearch in Prooress:Quantification of Small Pleural Fluid Collections by ComputedTomography (1991).
Eersonal and Professional References:Furnished on reauest.
WR R 9%9 90 L
**. a. .* e .wre v wwwe c,w..p evipurts cig6 e
j a%+-- "*** Hospital.
k**ac .*et-ev te , ga,a -, ,, ,
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, e i,. c., ,, .w . u%* Cat.forn.a 7.vem,e at 1 Sin $ttset
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CNcago. titeno<s 60608
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July 29, 1992 mm
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Terri Waschbisch sDirector, RadiologySt. Luke's Memorial liospital1320 Wisconsin Ave.Racine, Wisconsin 53405
RE: JANES A. TON 10LO, M.D.
Dear Miss Waschbisch:.
This is to certify that Doctor James A. Toniolowas trained in the interpretation of mammograms and theperformance of interventional procedures of the breast.during his radiology residency from July 1, 1988 June 301992, at Mount Sinai llospital Medien1 Center Chir.ago.
Sincerely, l. s-
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%1an flehe t , M.D.ChairmanDepartment of Radit.ugy
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N80 313M SUPPLEMENT D" U.S. NUCLEA. GULATORY COMMISSION-
PRECEPTOR STATEMENT* *
PROPOSED PHYSICIAN USER'S NAME AND ADDRESS*
FULL NAME: Scott Gage, M.D.
ADDRESS:CITY. ST ATE, ZIP CODE:
CLINICAL TRAINING AND EXPERIENCE OF ABOVE NAMED PliYSICIANNUMBER OF CASES
ISOTOPE CONDITIONS D|AGNOSED INVOLVING PERSONNEL COMMENTSOR TREATED PARTICIPATION
Thyrold scan 153Thyroid uptake 120Lung perfusion scan 428Xenon ventilation study 45"
Aerosol ventilation scan 0
Renal flow scan 179Brain scan 43Liver / spleen scan 56Done scan 1141<
Gastroesophageal study 21*
Leveen shunt study 0
Cystogram 2*- Dacrocystogram 0
,
Cardiac perfusion scan 648Cardiac stress ventriculogram 284'
Cardlac rest ventriculogram 920Gaillum scan 77
E151 White cell 137
Tc 99m Testicular scan 20
I n.111 Cisternogram 4
Tc 99m Gall bladder scan 153
T c.99 m GI bleed . 22
P 32(S) PV, leukemia, bene mets 2 (S) - SolubleP 32(C) Intracavitary treatment 0 (C) - Colloidal1131 treatment of hyperthyroidism 53
1131 treatment of thyroid carcinoma 9
Mo.93/Tc.99m Generator 5 l
Tc 99m Reagent Kits 15 |_
[ DATES AND TOTAL NUMBER OF HOURS RECEIVED IN CLINICAL RADidiaCTOi)E TRAININGl
Methodist Hospital,1701 N. Senale Blvd., Indianapolis, IN 46202 CLOCKHOURS OF
Aug 88 Feb 90 Aug 90 EXPERIENCE: | 756 |
Jun 89 Jun 90 Nov 91
| TRAINING AND EXPERIENCE INDICATED ABOVE OBTAINED UNDER THE SUPERVISION OF:
e odi t osp I W M '
1701 N. Senate Blvd. Larry L Hec /M.D. '/ /Indianapolis, IN 46202 Chairman, Radiation / / fMNRC License No. 13 02063 01 Safety Committeo / DATE -
.
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NRC 313M SUPPLEMENT A h U.S. NU;ut AR REGULATORY COMMISSION*
*
.
TRAINING AttD EXPifR!ENCE'
AUTHORIZED USER OR RADIATION SAFETY OFFICER"
NAME OF PROPOSED AUTHORIZED USER OR RADIATION SAFETY OFFICERFOR PHYSICIANS, STATE OR
TERRITORY WHERE LICENSED
Scott Gage, M.D.
CERTIFICATION ,
SPECIALTY BOARD C AT EGORY MONTH AND YEAR CERTIFIED
,
TRAINING RECEIVED IN BASIC RADIOISOTOPE HANDLING TECHNIQUESTYPE AND LENGTH OF TRAINING
LOCATION AND DATE(S) Clock Hours in ' Clock Hours of
FIELD OF TR AINING OF TRAINING Lecture or SupervisedLaboratory on the job
Erperience
Methodist Hospital of Indiana, Inc. ,
lRADIATION PHYSICS AND 1701 N. Senate BNd. 104 approximatoty
INSTRUMENTATION Indianapolis, IN 46202 10 ;
July 1988 through June 1992
RADIATION PROTECTION same 18 approximately10
MATHEMATICS PERT AINING TOTHE USE AND MEASUREMENT OF same 15 approximately
10RADIOACTIVITY
_
RADIATION BIOLOGY samo 27
RADIOPHARMACEL.1TICAL i, same 28 approximately10
CHEMISTRY
EXPERIENCE WITH RADIATION (Actual use of Radioisotopes or Equivalent Experience)
ISOTOPE AND mCl USED AT ONE TIME I.OC ATION CLOCK HOURS TYPE OF USE
Mo-99 Generator Methodist Hospital of Indiana, Inc. 756 hours Diagnosis
Tc90m 30 mci 1701 N. Senate BNd. and
Xe-133 25 mCl indianapolis,IN 46202 Therapy
1-131 20 mci NRC License No.13 02063-01in-111 1 mciGa 67 6 mci .
TI-201 4 mci1125 0.010 mci
man 93990r
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'
CWRICULUM VITAE
SCOTT W. GA G E, M.D.
t
ADDRESSES! Home 4
W nsin 53406414- 886-0582
.
Work: Racine Radiology Group SC..3803 Spring StreetPacine, Wisconsin 53405414-632-5580
-,
. . .
SOCIAL SECURITY #: 376 70 1106;
MARITAL STATUS: Married, Five Childrens
BIRT 11DATE: 11/11/61 ,-
BIRTilPLACE: Ann rbor,Michtgrai
CITIZENSilIP_: USA t'
iEDUCATION:
Enidency: Resident, Diagnostic Radiology 7/1/88 .PresentMethodist Hospital ofIndiana Completion 6/921701 North Senate Blvd. ' '
Indianapolis,IN 46202
Medica 13 thal: Indiana University M.D., May,1988 -School of Medicine (8/R4 - 5/88)Indianapolis,IN ,
'.
Collece: Indiana University B.S., May,1984Bloomington,IN Biochemistry
(8/80-5/84) .-Hirh School: - New Albany'High School Diploma, June,1980
New Albany,IN (8/77-6/80)
L1 CENSURE: Indiana ;
i
+
4
'
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Curriculum VitaeScott W. Gage, M.D.Page 2 r
!30ARDCERTIFICATION: National Boards, Part 1111
American Board of Radiology, Passed written exam 10/91,oral exam to be taken 6/92
,
IlONORS & AWARDS: J.Y. McCullough Academic Award,1987Thompson Award for Cardiac Research,1985E.B. Rinker Academic Award,1984Phi Beta Kappa Honorary Society,1984
'lPROFESSIONAL
MEMBERSillPS: Resident Member, Radiologic Society of North AmericaResident Member, Roentgen Ray Society
RESEARCll: " Evaluation of Reperfusion Hyperemia Using Myocardial ContrastEchocardiography",- Presented at National Medical Student Research Fomm,
Galveston, Texas, March,1986.- Presented at Midwest Medical Student Research Forum,
Ann Arbor, Michigan, November,1985.
LECTURES PRESENTEDIN POST GRADUATE ,
COURSES: " Liver and Gallbladder Ultrasound" Diagnostic Ultrasound Mini-Fellowship, St. Vincent's Hospital, Indianapolis, IN.Pn:sented: September,1988.
9
" Testicular Ultrasound", Diagnostic Ultrasound Mini Fellowship,St. Vincent's Hospital, Indianapolis, IN.Presented: September,1988
" Obstetrical Ultrasound", Diagnostic Ultrasound Mini Fellowship,Methodist Hospital of Indiana, Indianapolis, IN.Presented: March,1989; September,1990
"Nomul GYN Anatomy and Pathology", Diagnostic Ultmsound-Mini Fellowship, Methodist Hospital of Indiana, Indianapolis, IN,Presented: March,1989
. . - - - - - L- - . .
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STATE OF FLOf t|DA .
DEPARTMENT OF HEAllTH AND REHABilJTATIVE SERVICES*
May 27, 1992
David 11. Foidman, M.D.5000 Graceland Blvd.Apt. 241Racine, WI 53406
Dear Dr. Feldman:
Please find enclosed the following checked articles yourequested.
( ) Application for Radioactive Materials License(Hon-human use).
( ) Application Guide for Radioactive Materials License(human use).
( ) Preceptor / Applicant Statement.
( ) Certificate - Dispecition Radioactive Material.'
( ) Appendix of Medical Application.
( ) Florida Control of Radiation llazard Regulations
(100-91).
( ) Fee Schedule (llRS Regulatory Guide 6.20, Rev. 1).
(XX) Other Copy of Amendments #17 tq_ State of FloridaRadiocctIve Materials License #1071-1; andAmendment #3 to StcLte of Florida Radioactive14aterials Licensa #1099-1 .
If we may be of further assistance, please feel free to contactus.
Sincerely,
3k8 . . JCL
p,RadioactiveMaterialsSectionudith A. dordan
Office of Radiation ControlPhone: (904) 487-2437
Enclosures
1317 WINEWOOD BLVD * TALLAHASSEE FL 32399-0700
LAWTON CittllS. Ghl..RNOR
MR f93990
.
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DEPARTMENT OF llEALTH AND REllABILITATIVE SERVICES r - | '|. @~ - - ' ' '
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. ws% e Tellehessee, Floride 32301, '*:'
* [ RADIATION CONTROL ' ' Page 1 < of l ' ' Ph'7s' ,
-
RADIOACTIVE MATERIALS LICENSE,
.+ SUPPLEMENTARY SHEET . Utense Numte 1071-1-- -.
..' I4EDEff 10.17(SB)(IBS)*
. ,
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IURfAIOP.FIORIDA . -*
""d/Va Htrnna Hospital Bennett- - - a ~~ - -' >
.
.8201 West Broward Boulevard''~~~ ' e'Plantation, FL . 33324 *., (,; -- '- ~~~ ' - ,
, With referenm to correspondence dated Pay'20, .1985, State of Florida Radioactive Materials'License hwier 1071-1 is hereby acended as folicws:
. ,. ..
'IO Cide.GE (DtDITIDN 12 TO READ: _ .. .
....- .
(D!DITIOfS
12. Licensed uterial listrx1 in Itcsn 6 is authorized for use b/, or under the supervision of,the follcwing individuals for the mterials and uses indicated:
Authorized Material ard Uses h%:res -
-
t ,
All licensed material Ja:nes H. Sternberg, M.D.
Groups I, II, III, IV and xenon 133 Stephen Scfr.11r.nn, M.D.David Feldman, M.D.
Groups I, II, III and xenon 133 Mario thvarro, M.D.Marc H. Tranger, M.D.-Gerald Scirnidt, M.D. J
Ashley Y.aye, M.D. ./
:Monica Lau Leung, M.D.-Robert A. Pccniak, M.D.
.(
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|.
|
| \|
.-
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)
Date September 12- 19M Lyle i)Jerrett, Ph.D,Dire ~ 10r
7"|;.*L Radiation Control- . v a n n e - cr.
-
-
a,,MAJ.% Ay een] J M
m .ca.,i<|-' * * ' * ' * 01
.
'Padiation Cohtrol
HR$ Form 177, May B3 (Replaces Aug 81 edition wnich may to used)
- . , - . . . . . - - - . -. , . - . - - . -.- _. - - , - .. . . . - --. , . . .- ...- - --.--.z.~-
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- IlEAt.nl PROGRAM OfTKE . ucenw Numbes N-I'
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'r#- . Tsaahusee,f>wds 3230t (LLO)1323 weewood pows. . .
RADIOACTIVE M ATERIALS LICENSE N EhC+iENT N0* 3SUPPLEMENTARY SilEET.
f'. .''
'.i
L ' 'l'AP. GATE GENEP.A1. HOSPITAL' N. ~050,liargate Boulevard-
'e Margate, Florida 33063.
With reference tp letter dated floveriber 2%,1977, State of Florida RadioactiveMaterials License No.1099-1 is hereby arended as follows:
-
. . .
. . . .
%,. u . 'TO' CHANGE C0f7JITION ,12 TO READ: .[y" N ,., . . . .
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CCNDITIONS.,
12. Licens;d c.aterial shall be used by, or under the supervision of. Jares H.Sternberg, M.D. , Stephen A. Schbitaan, M.D. , Mario P. flavarro. !' D. , I.
, . .
Richard Mintz, M.D., David M. Feldman, it.D. or George Bosse M.D..
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FEB 00..__3wDate. r.. chariton trather, u.a., u.r.tt. ]Director, Health Program Office )I t,ncew . Whpie .N '
Co.rtret PHee + Canary - f,
[F 6 ens Fines Pina * e' 7
Put.16e informetton place . 36ue by V , ** * / / /
c$,"",",'.c$,,*L**" Radiological liech P*ogram||
| vaxn . . whne Tallahance. Flor.aa 32301 gt
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M ARG ATE GENER'AL HOSPITAL o osyW)
''.
|$860 MARGATE BOULEVARDMARGArE. FLORIDA 33063 ;
TELEPHONE (306) 9744400
AC.KNOWLEDE)
November 22, 1977,
p
.
'Bernhardt WarrenDepartment of Health
& Rehabilitative ServicesRadiological Health Program1323 Winewood Blvd.Tallahasse, Fla. 32301
Ref: License #1099-1 ,
Dear Mr. Uarren:
Picase amend our radioactive materials licenseto include the following physicians as authorized users:
1. David M. Feldman, M.D.2. George Bosse, M.D. ,
.
Copies of their preceptor statements and othersupporting data are enclosed.
Thank you for your attention to this reauest.Sincerely,
G. Robert BizAdministrator
: *
|b SENT _TO g g ni E D
DEC 0 21977 MC 0 " E; ''
FIELD FILES nas,,. ,.
gettsinL ;,..,
,
MER 93990L. - . . - - - - . - _ _ - _ _ - _ . - _ . _ . .-.
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W. Siato of FlorSo"
-
woAPPLICATION FOR R . OACTIVE MATERIALS L1 - MEDICAL %*
[**e 3 5UPPLIMlNT A-PktCCP10R SI AllMENT ggQ .J* r
Thes page is to be conipleted by the opplicone physic on's precepe r, il more than one pseceptor is necestotr lo documento
esperier.ce. obioin o separoie sooiemens from each. Boc k of page may be used for comments. .
e. # Amt AND Atut n1 O' 'Petec ANI reirsici4N gE19D 5.w 11 h .d . .bt . AN#30'1-EN6ATH L A ih otD m G , i: L A 3'3o65'
O. cum 6 CAL tt AtNW, AND 18PfllINCf Of PMvicAN Has*to IN 4tta t Asovt
(0)' ' '
(Al lli (C) .
40f0N CONQIllONS D ACN05f D Os le(Alep N.. C.se s Ob..... g N. C..e. 6a..l. e t.. i
(lee 1 wi6eys 4..) P .,... .,. . | 5. 3 .. g . , . . . ;
g.33) Diognosis of thytosd function / ,,*/ ' [1 / .?. fD61wt.on studies q f ' , > g.
_
Entretson sted.es . ,r p Je g~* *
6to,n tumot locoletoison .
-
$ conn.n,j studees
iteotment of hyperthyroidism / y,' ' y (!
Treatment os coedeoc conditionsTrea' ment c,f thyroid to,c nomo
''
F-32 l'eo' men'o' PoIY O '" e *'a
Soluble iteolment of leukemioTrootment of bone meiosicses19mor Ic.colisotion '
initoco.itory teeciment .
Inseestitial teeotment
Au- 98 Introcovatory i'eotmen' * .
, interstitial treatment
$ conning studies.
Cr-51 Blood d*Ierm'noi'oas _? y5 conning studies
._
Diognosis of perniciov< onerneo /J .2 M' * ~ '
Co-60_-C 6. - 6 0 iniersi.fiot treatment
1 192 Introco.itory treciment_
:c,-60 orTeletheropy treotment ,
Cs 137$#-90 Treotment of superf'('od'$eones of the eye g-
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Re{enences
Luglas A Smuh, AD. - k. Smuh is (hief of Radiology at St. by'.o bpual,90/-45th. 31., U'est Palm Beach, fl. 3507 (4of) 844-63X)
Kenneth f, fiAbhin, AD.- Dn. Puhhin u a dugnu1Lc nadiologiAl uhom i uvahed fon. ;
The (ove Taufessional Buildag, Suite 105,1500{. HLRabono Blvd.Deentield Ecach, fl 3p41, (95) 4M-yo5-
k. kny Saniels - On. Sannels uns the Chief of kdlology al the ihn Athon V, A.V. A. Medical (enien, Radiology Dept., 2215 Fullen kad,Ann Ad,on, 0148/05, (3/3) 769-7/m
b. Bennand Nelson, 7m %h St., !Nnneiha, la 60093, (7M) 446-8082On. Nelson is cuanently Vice (hainnan of the medicine dept. al(vanston bpUal, M50 Rid e Avenue, (vanslon, 11160211,9
(708) 570-axx), uhene i did my nesidency, intennship, and some of'
my medical school hainkg. b. Nelson knew me ueR duning myinnining peniod,[and I slLU {cel that he k the fincal docion Ahat
,
I have encountened)'
On. Atihun (nampton - 10 ny knoudedge, Dn. (nampton 4 ihe only allending nadiologist{ nom my haining pedod uho la sliR on the staff al (vansionbpual-( addness above }
h. gany R. Tonian, .. . ~ Dn. Tonian k a plastic sanocon uho uns {samtlian wuh my uenh.
uhen I ptacilced in the Plantation area, and he knows me up to.the ptesent day, 7370 N. U'. 5th. St., Plantation, fl 333/7,(DS) 791-3535
Dn. Aguel fimeney - k. fimene; e a p1aciicing nadiolopul in U'isconsh. U'e did oun.nesidencies al lhe same time al (vansion bpUal. He isoneofmy beal {niends and he knew mu jnsends ucR. 7/8 k{{odil,Belou,- U' I 5351|, (6M) 355-55%
Picase feel { nee lo contact any on all of lhe above hdividuals in negand to my p1ofcAsional~
_
abilUy, ainengik of chanacien, on peAsonal chanacienisticA.,
EdS 3'k9M
. - - -- - . ~ - . _ _ _ . . - . . - - . -
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kvi$!!.feldmn,AD..
1985 Itonhed fon 0,. kvid R. screchan (nadiologul) of ihe Talm &ach !cdical Gaoup,li'asi ?clm bach, florida and snainus locum lenens (including Da. Ken f. Puhkh,Deesfield &rach, fl and 01 Gene (oin of fupues, fl)
Owting ihls penind my fathen, l.ouiA feldean, uns diagnosed do be suffering facmpinc1ealic cancinowa. I theAefone indenupted wy active pnaclice of ardicineai lhis pin! so shal I could be of as mch help as pusible 10 him and sp'nd asnuch Jim as I could udA kim.
I look cane of my Dad until he paucd on. My folhen, radan feldmn, had beenquite dep.ndent on my falhen befone he became ill. In addition, ny tvihen unseldenly and h facil health. Subsequent to my falher's pasing, I therefonehelped and caned for ni folhen until she also pwsed on, app,oximlely inv andone half yeau laden,
th execulon, I, along ud.dk Aheh allonney h'enbert fay (ohen of Piami, fl., lookcane of the stutinus lhings lhal lhek eslade necealfaled. I look my lime adjusthglo uhal uns a veny significant hus for me and for uhat had been a veAy layingpesied duning ny p1nents declining yeau. I have numenous hobbies uhich?hclulelaumpet playhg, printing, and uniling; and I occuppied my lhe productively wilkthese pinuik,
kah9 ihe above ponlod, I lulened each mnik lo lhe inactical Revicu>s in RadiologyTape Senies so that I could keep up wilk ihc lalesi developenents k my speciallyand also sailafy ihe ( 5l acquhements (along uilh auending cealah acquhedseminans) so ihal I could anhiain avj florida xdical license. Recenlly, I attendeda veay comprehensive Radiolo9y Revico Couue spasoned by the Univenity of PianiSchool of radiche.1 enjoyed the confesence 9scally, and I am now anxinus 10 gelback hio lhe active p,actice of my specially,
s
Thankyou veny auch for allendion and kind consideaallon in negand to the above /
.
A
gen a 93990. . . . . - .-- . . .. .
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&W1D A F[f.MAY, AD.,,
..
, ,
TRAINEA9 and {al(ATICV-
Residency 1969-1972 (vansion bpilah bwlon, IRinois(paal of the Norihussiem Univen.silyisainingsystem)
Inained in genenal aadiolopy. Ian years spen)in diagnoslic audiolc99 and one yeaa anuclean inedicine and acdialion 1henapy.
Inicanship 1968-1969 (vansion bpila4 (vansion, IRinois
[xpenienced a slaalghi medical indennship
wilk elective mniks in nadiology and pzth-
*I"9V
Doctor of fedicine 1968 NorthaesleAn Univensity.
B. A. Ocpace 19 9 Northuestenn Univessily(anjoa in biology)
l.icensune Dec. 1975 (erlified in Genenal kdiology by ihe kuicankand of kdlology
(unrenlly licensed do p<actice mediche inFlorida
filitany 1972-1974 ' United Slales Au Fonee rajoa)Hospital (.(.K., Taiuan (one of ike unin
~.buppoal bases daning the Viel Nam conflict) for15 evnik loat of duly
\ Palaich Au fonce %e, (oco Beach, Florida
for a 9 acalk four of duly
Personal kan 8 Sept.1942 '(Citicago, IRinois)!arital Sialas--Divorced
*
Intenesis--All foams of she Fine Axisincludini literatuac, ensic (au lypes, esp.ja53 and class.ical, including opena)I, myself, tutile, pahl, play laumpel,and enjoy exescise (sep. bicyclink).
. . . _ _ _ . - -. --
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LH'10 A fflDW AD. h* '
,
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5% N.W. 44LA. 51. A t.#6/lPlauderhill, Flanida 33]I9
005)485-27E0
6t?IDJf6W1974-1976 Univensity of richigan, kn A1 bon, tichigan
insinneloa in Radiology%ponsibiluies incided leaching and uvaking with assidents in theDeputiren) of Diagnostic Padiology. A1cas of spcial inte<csi includedskeletal and gasstointestinal nadiology.
1976-1982 fans Slesnbesg, Sleven Sebulann & AmcLaies, AD., P. AFont laudendale, FloaldaAssociaic
A General Olognoslic Radiology nactice including. Nucleat fedicineF
Five nadiologists ucne associaled in lhe p,aelice ukick included affiliationunik luu primte hospliala
1982-1983 Da. Douglas A Smuh, AD., P. A.St. ky's bpualll'est Palm Beach, Floalda
/n exlended eleven annik locum lenens uvaking for Dr. SmUh in a GenemlDiognutic Radiology inactice. Thene uns also a fine school for nadiologicallechnologista ukick uns auociated wuh AALs depz11 ment. .
l983-1984 V. A. bpital, Ann A1 bon, tichiganUniveulty of Pickipan-InsL1ucion in Podiology
Six neniks uvaking in geneAal nadiology and sindying ' compted lonognaphy.Some Line synl udh On. Ingvan Anderuon (from Suceden), an expeni innnevognaphy.
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B
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CBNELNil 98990.
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O O ;-
<
N0V 1't1992 ,
Racine Medical Clinic {ATTN: Diane H. Johnson, R.T.N.
Director of Radiology3708 Spring StreetRacine, WI 53405
Dear Hs. Johnson:
As discussed by phone on November 10, 1992, we are voiding youramendment request at this time. Below is a excerpt from ourdeficiency letter dated October 2, 1992 outlining the areas thatwere deficiunt.
,
Excerpt:
10 CFR Part 35, Section 35.920 of Subpart J requiresthat a physician user have 200 hours of didactictraining.along with 500 hours of supervised workexperience AND 500 of supervised clinical experiencefor a total of 1000 hours of training, OR, hassuccessfully completed a six-month training program innuclear medicine, OR, has a certificate from one ofthrea certification boards. In addition, Section35.972 requires that the training must have beenreceived within the five years preceding the date ofthe application to be added as an authorized used.Drs. Toniolo, Gage, and Feldman do not appear to meetthe criteria in Part 35. The deficiencies are as "
follows:
Dr.-Toniolo does not appear to meet the requirementscutlined in 10 CFD 35.920 (b) (1) (2) and (3) for use of35.200 materials.
I was unable to verify Dr. Gage's certification withthe American Board of Radiology. His preceptorstatement documents only 756 hours rather than therequired 1000 hours. Please submit a copy of hiscertificate or an another preceptor statementdocumenting additional hours to satisfy the 1000 hourrequirement.
Dr. Feldman is listed.on Florida-License No. 1071-1amendment no. 17, dated September 12, 1985. Verifythat.Dr. Feldman has had continuing experience in thefield during the past five years. (1987 to the.present)..
When you are ready to resubmit the documentation necessary tocomplete this amendment, please mention that it is additionalinformation to Control Number 93990 and not a new request,
g'
, _ . - _ . - .
O . ovm99h-
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,
If you have any questions or require clarification on any_of theinformation states above, you may contact us at (708) 790-5625~.
Sincerely,
Patricia M. VacherlonLicenso Reviewer
, . ..
/
'[''
I. acherlonX1/10/92-
_V
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4 9 !
R KlNE <.,
,
MEDCALClJNiC i
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October 19, 1992 tu.,,, i s..,
"PL a.a.n. ."%e,
. u na t.
E'M$.*Gf"#se .cu roaun%do $c U.S. Nuclear Regulatory Commission !
j'n'MJ "d' Region 111"c*ub e-
>
[dC.".JfuuacW 799 Roosevelt Road
uu . u u,% Glen Ellyn, IL 60137
MT,'Oht RE: Control #93990N'id ",".riA T " * ~' '
Ocar Ms. Yacherlon:gg,igy,ug.1
077.% uoac ! am in receipt of your letter . dated 10-2-92 concerning ourgg|3-gug- application to add three physicians to our license.u a,s.r u asc.E RTi'S~,'liCli*'*~ We are in the process of providing more information- to meet the
criteria. ;ggi ,,yuao,.7
5.h35'.':"Eu na c We will attempt to gather additional preceptor documentation from,
{t e rm.... u nacthe training programs of Doctors' Gage and Toniolo. Dr. Feldman{WyWehas not had continuining experience for the past 5 years.
!Mif.?Le .;
. m.+.a.~g . Dr. Feldman has been working for the Racine Radiology Group since| ] ] 7
'y'October 26~, 1991. Dr. Toniolo has been employed since June 28,
if |, gi,%5t 1991 and Dr. Gage since July --12, 1991. They all have bc3n s
h'k"7||d": engaged in Nuclear Medicine practice at Racine Medical Clinic,li';iL".!|:,h@,.u St. Mary's Medical - Center and--St. Luke's Hospital in Racine,
sr,
WC':::C% Wisconsin. -
M h%W"c -
u* ma.**oac Preceptor statements will be submitted by Doctors' Arnold|fdfd,7;t'?? Strimling and D.H. Kim verifying the experience during these,
i t u. wdh periods.E N unacj.
If yet..have any questions or require clarification on the :abovem . i-i-r
,C,[ "" " information, please contact us at (414)-631-8131.J D. t uoa. M D E c
C"tMWLoc Sincerely,':
W'Th%272A}h(4Jr [O
G 77Lt fh :c . m,, c.,u,,,
Yr"CMY, &u rm.. u n Diane M. Johnson, R.T.N.
L it.n;7.,- Director of Radiology '
: u,
DJ/lm
RECEIVED; - m - s u -i ci e
m1M7 Spnng $1reet ;} ' g, -
P.O. Ikn 0R5U01 - g g. beine,3%sconsm $M!EN01
,
(414)(31-8011 ii
REGION III-r
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OCT <0 01992 MRacine Medf^al ClinicATTN: Die- M. Johnson, R.T.N.
Director of Radiology370R apring StreetRacine, WI 53405
Dear Ms. Johnson:
We m. > viewed you'. Toptember 3, 1992 request for an amendmentnhysicians to your licensa. We find that we willt er
a not - 1 information before we can complete our review.'
;P 10 e rn . ( ' lu, Section 35.420 of Subpart J requires that a' phy31cio.- r have 200 hours of didactic training along with 500
hours yervised work experience AND 500 of supervised _
#
; clir :, ~9rience for a total of 10]O hours of training, OR,~
has sur e. 11y completed a six-month training program ina a c i t-e r m e e . c ir.e , OR, has a certificate from one of threecertif&cstica boardc. In addition, Section 35.972 requires thatthe t'aining must have been received wLthin the five yearspreceding the date of the application to be added as anauthcrized used. Drs. Toniolc, Gage, and Feldman do not appear
'
to meet the criteria in Part 35. The deficiencies are asfellows:
Dr. Toni lo does not appear to meet the requirements outlined in10 CFR 35.920 (b) (1) (2) and (3) for use of 200 materials.
I was unable to ver i Dr. Gage's certification with the AmericanBoard of P;'iology. His procuptor statement documents only 756hours rac we than the requiicd 1000 hours. Please submit a copyof h.t certificate or an another preceptor statenent documentingadditional hours to satisfy the 1000 hour requirement.
-T
Pr. Feldman is . tol on Florida License No. 1071-1 amendment no.17, d&Lnl September 12, 1925. Verify that Dr. Feldman has hadcontinuing exiurience in the field dering the past five years.(1987 to the present).
We will continue car review of your application upon receipt ofthis information. Please reply in duplicate, within 30 days, andrefer to Control !; umber 93990.
-.- ,
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9 9,
OCT 0 21992 fld. ..
Upon failure to file answer within the specified time, we willconsider that -yoit-have abandoned your request and will void thisaction. This is without prejudice to resubmission of theapplication.
If you have any questions or require clarification on any of theinformation states above, you may contact us at (708) 790-5625.
Sincerely,
Patricia M. VacherlonLicense Reviewer
,
,f? EPMVacherlon9/jd/92y'}.