Basic Information
Provider Information | |||||||||
NPI: | 1164519419 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDICAL ONCOLOGY & HEMATOLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DIAGNOSTIC HEMATOLOGY LAB | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19 LUNAR DRIVE | ||||||||
Address2: | MEDICAL ONCOLOGY AND HEMATOLOGY PC | ||||||||
City: | WOODBRIDGE | ||||||||
State: | CT | ||||||||
PostalCode: | 06525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033897504 | ||||||||
FaxNumber: | 2033891666 | ||||||||
Practice Location | |||||||||
Address1: | 240 INDIAN RIVER RD | ||||||||
Address2: | SUITE A1 | ||||||||
City: | ORANGE | ||||||||
State: | CT | ||||||||
PostalCode: | 064773649 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037951664 | ||||||||
FaxNumber: | 2037951665 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2006 | ||||||||
LastUpdateDate: | 03/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WARANOWICZ | ||||||||
AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2033897504 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MEDICAL ONCOLOGY & HEMATOLOGY PC | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | CL0172 | CT | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 07D0098236 | 01 | CT | CMS CLIA | OTHER | CL0172 | 01 | CT | DEPT OF PUBLIC HEALTH LIC | OTHER |