Basic Information
| Provider Information | |||||||||
| NPI: | 1851324370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | WANG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WANG | ||||||||
| OtherFirstName: | NANCY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | 1ST FL,MSC9152 | ||||||||
| City: | SHAKER HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866299 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447494 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 35-069513 | OH | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 743236 | 01 | OH | BUCKEYE | OTHER | P00454334 | 01 | OH | RAILROAD MEDICARE | OTHER | 1851324370 | 01 | OH | MI MEDICAID | OTHER | 220029791 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000224339 | 01 | OH | UNISON | OTHER | 000000528781 | 01 | OH | ANTHEM | OTHER | 364110 | 01 | OH | WELLCARE | OTHER | 000000188079 | 01 | OH | ANTHEM | OTHER | 2068157 | 01 | OH | UHC | OTHER | 0127464 | 01 | OH | BCMH | OTHER | 2213250 | 05 | OH | MEDICAID | 7849101 | 01 | OH | AETNA | OTHER |