Basic Information
| Provider Information | |||||||||
| NPI: | 1275250805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN CT HEMATOLOGY & ONCOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 WASHINGTON ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609122147 | ||||||||
| FaxNumber: | 8608869262 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 WASHINGTON ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609122147 | ||||||||
| FaxNumber: | 8608869262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2022 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING LEAD | ||||||||
| AuthorizedOfficialTelephone: | 8609122147 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EASTERN CT HEMATOLOGY & ONCOLOGY | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
No ID Information.