Provider Demographics
NPI:1386672277
Name:ONCO DIAGNOSTIC LABORATORY
Entity Type:Organization
Organization Name:ONCO DIAGNOSTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANHO
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-546-0200
Mailing Address - Street 1:PO BOX 72501
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44192-0501
Mailing Address - Country:US
Mailing Address - Phone:706-546-0200
Mailing Address - Fax:706-546-6522
Practice Address - Street 1:812 HURON RD E
Practice Address - Street 2:SUITE 520
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-1123
Practice Address - Country:US
Practice Address - Phone:216-861-5846
Practice Address - Fax:216-861-1720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35031213207ZP0101X
OH36D0656045291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0893547Medicaid
OH0893547Medicaid
OHD369321Medicare PIN