MEDICARE: LOS ANGELES HEMATOLOGY-ONCOLOGY MEDICAL GROUP

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	207RH0003X	Hematology & Oncology Physician

General Provider Information

NPI Number	:	1871210708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOS ANGELES HEMATOLOGY-ONCOLOGY MEDICAL GROUP

Provider Business Mailing Address
First Line	:	541 W COLORADO ST STE 205
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91204-3640
Country	:	US
Telephone Number	:	323-794-1403
Fax Number	:	323-488-9782

Provider Business Practice Location Address
First Line	:	3650 SOUTH ST STE 212
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-1528
Country	:	US
Telephone Number	:	562-272-7630
Fax Number	:	562-272-7631

Authorized Official
Title or Position	:	PROJECT MANAGER
Name	:	MARLA LOU WSIAKI
Credential	:
Telephone Number	:	323-254-0046

Provider Enumeration Date	:	10/21/2022
Last Update Date	:	10/21/2022

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