Basic Information
| Provider Information | |||||||||
| NPI: | 1750385183 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ONCOLOGY HEMATOLOGY MEDICAL ASSOCIATES OF THE CENTRAL COAST | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ONCOLOGY HEMATOLOGY MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 TANK FARM ROAD | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055435577 | ||||||||
| FaxNumber: | 8055953231 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 TANK FARM ROAD | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055435577 | ||||||||
| FaxNumber: | 8055953231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | SPILLANE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8055435577 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 2368027 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ02934Z-22 | 01 | CA | BLUE SHIELD PIN | OTHER | 1018 | 01 | CA | CMSP GROUP PIN | OTHER | GR0091140 | 05 | CA | MEDICAID |