Basic Information
| Provider Information | |||||||||
| NPI: | 1811929334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOON | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SHAKER HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866295 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVENUE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168443951 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 01/23/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 154133 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000000221364 | 01 | OH | UNISUN | OTHER | 000000527718 | 01 | OH | ANTHEM | OTHER | 2762587 | 05 | OH | MEDICAID | 414994 | 01 | OH | WELLCARE | OTHER | 750817 | 01 | OH | BUCKEYE | OTHER | 7538343 | 01 | OH | AETNA | OTHER |