Healthcare Provider Details

I. General information

NPI: 1215933239
Provider Name (Legal Business Name): TRINITY HEMATOLOGY & ONCOLOGY CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 03/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 CAPE CT
FAYETTEVILLE NC
28304-4404
US

IV. Provider business mailing address

PO BOX 87427
FAYETTEVILLE NC
28304-7427
US

V. Phone/Fax

Practice location:
  • Phone: 910-485-7003
  • Fax: 910-485-7103
Mailing address:
  • Phone: 910-485-7003
  • Fax: 910-485-7103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number9701004
License Number StateNC

VIII. Authorized Official

Name: DR. MARK KETHEESWARAN
Title or Position: ATTENDING PHYSICIAN
Credential: MD
Phone: 910-485-7003