Basic Information
| Provider Information | |||||||||
| NPI: | 1053348904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANCER NETWORK OF WEST CENTRAL OHIO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAND LAKE REGIONAL CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 HAVEMANN ROAD | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458221870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195841900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 HAVEMANN ROAD | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458221870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195841900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLEMMENTS | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 4192512662 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE CANCER NETWORK OF WEST CENTRAL OHIO | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0203X | 1055RT | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology, Radiation |
ID Information
| ID | Type | State | Issuer | Description | 2429821 | 05 | OH | MEDICAID |