Provider Demographics
NPI:1508926759
Name:SUBURBAN HEMATOLOGY ONCOLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:SUBURBAN HEMATOLOGY ONCOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-533-1555
Mailing Address - Street 1:631 PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7650
Mailing Address - Country:US
Mailing Address - Phone:770-963-8030
Mailing Address - Fax:770-339-9577
Practice Address - Street 1:631 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 450
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7651
Practice Address - Country:US
Practice Address - Phone:770-963-8030
Practice Address - Fax:770-339-9577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACH5181OtherMEDICARE RAILROAD GRP#
GA4188940003Medicare NSC
GA900003457Medicare PIN
GA900003456Medicare PIN
GACH5181OtherMEDICARE RAILROAD GRP#
GA4188940001Medicare NSC
900003458Medicare PIN
GAP00024271Medicare PIN
GRP3891Medicare ID - Type Unspecified
GA900003455Medicare PIN