1750385183 NPI number — ONCOLOGY HEMATOLOGY MEDICAL ASSOCIATES OF THE CENTRAL COAST

Table of content: (NPI 1750385183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750385183 NPI number — ONCOLOGY HEMATOLOGY MEDICAL ASSOCIATES OF THE CENTRAL COAST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONCOLOGY HEMATOLOGY MEDICAL ASSOCIATES OF THE CENTRAL COAST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ONCOLOGY HEMATOLOGY MEDICAL ASSOCIATES
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750385183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
715 TANK FARM ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93401-4140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-543-5577
Provider Business Mailing Address Fax Number:
805-595-3231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 TANK FARM ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-4140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-543-5577
Provider Business Practice Location Address Fax Number:
805-595-3231
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SPILLANE
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-543-5577

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  2368027 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ02934Z-22 . This is a "BLUE SHIELD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1018 . This is a "CMSP GROUP PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0091140 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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