Basic Information
| Provider Information | |||||||||
| NPI: | 1194824862 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLANCHARD VALLEY REGIONAL CANCER CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636320 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194296499 | ||||||||
| FaxNumber: | 4194296494 | ||||||||
| Practice Location | |||||||||
| Address1: | 15990 MEDICAL DR S | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458408894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194233703 | ||||||||
| FaxNumber: | 4194270212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 04/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | CYTLAK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4194235497 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0084779 | 05 | OH | MEDICAID | P00349396 | 01 | OH | RAILROAD CARE | OTHER |