Healthcare Provider Details

I. General information

NPI: 1750307278
Provider Name (Legal Business Name): EAST VALLEY HEMATOLGY AND ONCOLOGY MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 S BUENA VISTA ST 4RTH FLOOR
BURBANK CA
91505-4504
US

IV. Provider business mailing address

PO BOX 51194
LOS ANGELES CA
90051-5494
US

V. Phone/Fax

Practice location:
  • Phone: 818-840-0921
  • Fax: 818-840-7064
Mailing address:
  • Phone: 818-840-0921
  • Fax: 818-840-7064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberG62813
License Number StateCA

VIII. Authorized Official

Name: EDWIN JACOBS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 818-840-0921