Provider Demographics
NPI:1942414412
Name:SUBURBAN HEMATOLOGY ONCOLOGY INC
Entity type:Organization
Organization Name:SUBURBAN HEMATOLOGY ONCOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-378-0900
Mailing Address - Street 1:6463 TAYLOR MILL RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-9392
Mailing Address - Country:US
Mailing Address - Phone:859-363-4900
Mailing Address - Fax:859-363-4986
Practice Address - Street 1:3619 PARK EAST DR
Practice Address - Street 2:SUITE 211
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4330
Practice Address - Country:US
Practice Address - Phone:216-378-0900
Practice Address - Fax:216-378-1853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHWI032845207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0304585Medicaid
OHC00981Medicare UPIN
OH0304585Medicaid