Provider Demographics
NPI:1720465818
Name:MIDWEST BLOOD AND CANCER SPECIALISTS, LLC
Entity type:Organization
Organization Name:MIDWEST BLOOD AND CANCER SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JYOTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-398-1971
Mailing Address - Street 1:2355 DERR RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2439
Mailing Address - Country:US
Mailing Address - Phone:937-398-1971
Mailing Address - Fax:937-629-3601
Practice Address - Street 1:2355 DERR RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2439
Practice Address - Country:US
Practice Address - Phone:937-398-1971
Practice Address - Fax:937-629-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-28
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-090413207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty