1154384758 NPI number — METROPOLITAN HEMATOLOGY ONCOLOGY MEDICAL GROUP, INC

Table of content: (NPI 1154384758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154384758 NPI number — METROPOLITAN HEMATOLOGY ONCOLOGY MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METROPOLITAN HEMATOLOGY ONCOLOGY MEDICAL GROUP, INC
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:
Provider Other Organization Name Type Code:
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:
1154384758
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 81172
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN MARINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91118-1172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-484-6474
Provider Business Mailing Address Fax Number:
213-484-8470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 S ALVARADO STREET
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90057-2394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-484-6474
Provider Business Practice Location Address Fax Number:
213-484-8470
Provider Enumeration Date:
04/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
PETER
Authorized Official Middle Name:
SAMUEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
213-484-6474

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  C38037 , 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: GR0064910 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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