Healthcare Provider Details

I. General information

NPI: 1275849788
Provider Name (Legal Business Name): SHINOJ PATTALI JAYAVALSAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MATTHEW ST STRECKER CANCER CENTER
MARIETTA OH
45750-1644
US

IV. Provider business mailing address

PO BOX 449
MARIETTA OH
45750-0449
US

V. Phone/Fax

Practice location:
  • Phone: 740-376-5000
  • Fax: 740-376-5002
Mailing address:
  • Phone: 740-374-4500
  • Fax: 740-374-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125057348
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number35.127465
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: