Provider Demographics
NPI:1215933239
Name:TRINITY HEMATOLOGY & ONCOLOGY CENTER PA
Entity type:Organization
Organization Name:TRINITY HEMATOLOGY & ONCOLOGY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTENDING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KETHEESWARAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-485-7003
Mailing Address - Street 1:PO BOX 87427
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-7427
Mailing Address - Country:US
Mailing Address - Phone:910-485-7003
Mailing Address - Fax:910-485-7103
Practice Address - Street 1:1209 CAPE CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4404
Practice Address - Country:US
Practice Address - Phone:910-485-7003
Practice Address - Fax:910-485-7103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701004207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7901814Medicaid
NC01814OtherBLUE CROSS & BLUE SHIELD
NC7901814Medicaid