1295874014 NPI number — MICHIANA HEMATOLOGY ONCOLOGY OF MICHIGAN, P.C.

Table of content: (NPI 1295874014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295874014 NPI number — MICHIANA HEMATOLOGY ONCOLOGY OF MICHIGAN, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIANA HEMATOLOGY ONCOLOGY OF MICHIGAN, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295874014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 NAVARRE PL
Provider Second Line Business Mailing Address:
SUITE 6695
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46601-1156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-234-5123
Provider Business Mailing Address Fax Number:
574-237-1341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 LONGMEADOW DRIVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
NILES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-683-4153
Provider Business Practice Location Address Fax Number:
269-683-4154
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANSARI
Authorized Official First Name:
RAFAT
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
574-234-5123

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207VX0201X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OA11038 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4815650001 . This is a "NSC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: DA4426 . This is a "RRMC PROVIDER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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