Basic Information
Provider Information | |||||||||
NPI: | 1205867868 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY PHYSICIANS ONCOLOGY HEMATOLOGY GROUP, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 256 MASON AVE | ||||||||
Address2: |   | ||||||||
City: | STATEN ISLAND | ||||||||
State: | NY | ||||||||
PostalCode: | 103053408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182266400 | ||||||||
FaxNumber: | 7182266404 | ||||||||
Practice Location | |||||||||
Address1: | 256 MASON AVE | ||||||||
Address2: |   | ||||||||
City: | STATEN ISLAND | ||||||||
State: | NY | ||||||||
PostalCode: | 103053408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7182266400 | ||||||||
FaxNumber: | 7182266404 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2006 | ||||||||
LastUpdateDate: | 07/06/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FORTE | ||||||||
AuthorizedOfficialFirstName: | FRANK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7182266400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | CI0429 | 01 | NY | RAILROAD MEDICARE | OTHER |