1114129574 NPI number — HEMATOLOGY ONCOLOGY ASSOC LTD

Table of content: (NPI 1114129574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114129574 NPI number — HEMATOLOGY ONCOLOGY ASSOC LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEMATOLOGY ONCOLOGY ASSOC LTD
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:
1114129574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5226 DAWES AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-379-9111
Provider Business Mailing Address Fax Number:
703-931-7952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5226 DAWES AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-379-9111
Provider Business Practice Location Address Fax Number:
703-931-7952
Provider Enumeration Date:
06/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
LEROY
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-379-9111

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  0101018898 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6024262 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001 . This is a "BS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 3600054 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 37380001 . This is a "ALLIANCE CAPITAL CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6024262 . This is a "MEDICAID UNICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 017081 . This is a "BSVA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 212333 . This is a "MDSPA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 281815 . This is a "AMERIGROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3738 . This is a "BS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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