1386672277 NPI number — ONCO DIAGNOSTIC LABORATORY

Table of content: (NPI 1386672277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386672277 NPI number — ONCO DIAGNOSTIC LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ONCO DIAGNOSTIC LABORATORY
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:
1386672277
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 72501
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44192-0501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-546-0200
Provider Business Mailing Address Fax Number:
706-546-6522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
812 HURON RD E
Provider Second Line Business Practice Location Address:
SUITE 520
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44115-1123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-861-5846
Provider Business Practice Location Address Fax Number:
216-861-1720
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
CHANHO
Authorized Official Middle Name:
H
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
706-546-0200

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0101X , with the licence number:  35031213 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X , with the licence number: 36D0656045 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0893547 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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