Basic Information
| Provider Information | |||||||||
| NPI: | 1912959016 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEMATOLOGY ONCOLOGY CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41201 SCHADDEN RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440352220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403240401 | ||||||||
| FaxNumber: | 4403240405 | ||||||||
| Practice Location | |||||||||
| Address1: | 41201 SCHADDEN RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440352220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403240401 | ||||||||
| FaxNumber: | 4403240405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 02/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | KANTHARAJ | ||||||||
| AuthorizedOfficialFirstName: | BELAGODU | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4403240401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 0279541 | 05 | OH | MEDICAID | 1513889 | 01 | OH | UNITED MINE WORKERS | OTHER |