Healthcare Provider Details

I. General information

NPI: 1720465818
Provider Name (Legal Business Name): MIDWEST BLOOD AND CANCER SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 DERR RD
SPRINGFIELD OH
45503-2439
US

IV. Provider business mailing address

2355 DERR RD
SPRINGFIELD OH
45503-2439
US

V. Phone/Fax

Practice location:
  • Phone: 937-398-1971
  • Fax: 937-629-3601
Mailing address:
  • Phone: 937-398-1971
  • Fax: 937-629-3601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number35-090413
License Number StateOH

VIII. Authorized Official

Name: JYOTHI CHALLA
Title or Position: OWNER
Credential: MD
Phone: 937-398-1971