MEDICARE: ONCO DIAGNOSTIC LABORATORY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	36D0656045	OH
2	207ZP0101X	Anatomic Pathology Physician	35031213	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386672277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONCO DIAGNOSTIC LABORATORY

Provider Business Mailing Address
First Line	:	PO BOX 72501
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44192-0501
Country	:	US
Telephone Number	:	706-546-0200
Fax Number	:	706-546-6522

Provider Business Practice Location Address
First Line	:	812 HURON RD E
Second Line	:	SUITE 520
City	:	CLEVELAND
State	:	OH
Zip	:	44115-1123
Country	:	US
Telephone Number	:	216-861-5846
Fax Number	:	216-861-1720

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. CHANHO H PARK
Credential	:	M.D.
Telephone Number	:	706-546-0200

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/22/2011

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Directions to “ONCO DIAGNOSTIC LABORATORY ” Practice Location

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