=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497991319
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH COAST ONCOLOGY & HEMATOLOGY A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2008
-----------------------------------------------------
Last Update Date | 04/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1773 HARRISON AVE
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-1338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-444-8711
-----------------------------------------------------
Fax | 707-444-2084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1773 HARRISON AVE
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-1338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-444-8711
-----------------------------------------------------
Fax | 707-444-2084
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ ADMINISTRATOR
-----------------------------------------------------
Name | HOWARD FELLOWS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 707-444-8711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | G88376
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------