Provider Demographics
NPI:1114051190
Name:NORTH VALLEY HEMATOLOGY ONCOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:NORTH VALLEY HEMATOLOGY ONCOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:ENGLE-BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-773-6366
Mailing Address - Street 1:7657 WINNETKA AVE
Mailing Address - Street 2:PMB 307
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91306-2677
Mailing Address - Country:US
Mailing Address - Phone:818-773-6363
Mailing Address - Fax:818-773-9503
Practice Address - Street 1:18300 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4105
Practice Address - Country:US
Practice Address - Phone:818-773-6363
Practice Address - Fax:818-886-3743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11618Medicare ID - Type Unspecified
CA0163770001Medicare NSC