Basic Information
| Provider Information | |||||||||
| NPI: | 1922192079 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL ONCOLOGY & HEMATOLOGY PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DIAGNOSTIC HEMATOLOGY LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 LUNAR DRIVE | ||||||||
| Address2: | MEDICAL ONCOLOGY & HEMATOLOGY PC | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033897504 | ||||||||
| FaxNumber: | 2033898854 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 CHASE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037556311 | ||||||||
| FaxNumber: | 2037556263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 09/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | WARANOWICZ | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2035897504 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDICAL ONCOLOGY & HEMATOLOGY PC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | CL0599 | CT | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | G7D0664949 | 01 | CT | CLIA | OTHER | CL0599 | 01 | CT | DPH | OTHER | G7D0664949 | 01 | CT | CMS | OTHER | CL0599 | 01 | CT | LICENSE | OTHER |