Provider Demographics
NPI:1477721868
Name:EAST VALLEY HEMATOLOGY ONCOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:EAST VALLEY HEMATOLOGY ONCOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-840-0921
Mailing Address - Street 1:PO BOX 51194
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-5494
Mailing Address - Country:US
Mailing Address - Phone:818-840-0921
Mailing Address - Fax:818-840-7064
Practice Address - Street 1:181 S BUENA VISTA ST
Practice Address - Street 2:4RTH FLOOR
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4504
Practice Address - Country:US
Practice Address - Phone:818-840-0921
Practice Address - Fax:818-840-7064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB61363FMedicaid