Provider Demographics
NPI:1518041342
Name:JAMESTOWN MEDICAL ONCOLOGY HEMATOLOGY, LLC
Entity Type:Organization
Organization Name:JAMESTOWN MEDICAL ONCOLOGY HEMATOLOGY, LLC
Other - Org Name:JAMESTOWN MEDICAL ONCOLOGY HEMATOLOGY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:GABUTEN
Authorized Official - Last Name:IBABAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-664-1909
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14702-0009
Mailing Address - Country:US
Mailing Address - Phone:716-664-1909
Mailing Address - Fax:716-664-2214
Practice Address - Street 1:21 PORTER AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6247
Practice Address - Country:US
Practice Address - Phone:716-664-1909
Practice Address - Fax:716-664-2214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11303OtherMAGNACARE
NY040403007130OtherFIDELIS
NY02365855Medicaid
NY714714OtherMVP
NY000524493003OtherBCBS OF WNY
NY7200341OtherGHI
NY000866280OtherMGP
NY00010352702OtherUNIVERA HEALTHCARE
NY0007232005OtherAETNA
NYAA0630OtherMEDICARE
NY0191329OtherINDEPENDENT HEALTH
NY1294660001OtherNHIC DME JURISDICTION A
NYCG8430OtherRR MEDICARE
NY0007232005OtherAETNA
NY0191329OtherINDEPENDENT HEALTH