Basic Information
| Provider Information | |||||||||
| NPI: | 1073549648 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL ONCOLOGY & HEMATOLOGY, PC | ||||||||
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| OtherOrganizationName: | DIAGNOSTIC HEMATOLOGY LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 LUNAR DRIVE | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033897504 | ||||||||
| FaxNumber: | 2033891666 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 LUNAR DRIVE | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033897504 | ||||||||
| FaxNumber: | 2033891666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | COPPOLA | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2033897504 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 004001459 | 05 | CT | MEDICAID |