Provider Demographics
NPI:1073549648
Name:MEDICAL ONCOLOGY & HEMATOLOGY, PC
Entity Type:Organization
Organization Name:MEDICAL ONCOLOGY & HEMATOLOGY, PC
Other - Org Name:DIAGNOSTIC HEMATOLOGY LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:203-389-7504
Mailing Address - Street 1:19 LUNAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525
Mailing Address - Country:US
Mailing Address - Phone:203-389-7504
Mailing Address - Fax:203-389-1666
Practice Address - Street 1:19 LUNAR DRIVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525
Practice Address - Country:US
Practice Address - Phone:203-389-7504
Practice Address - Fax:203-389-1666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004001459Medicaid
690003007Medicare PIN
C00657Medicare ID - Type Unspecified
CM1770Medicare PIN