Provider Demographics
NPI:1003955485
Name:MICHIANA HEMATOLOGY-ONCOLOGY P C
Entity Type:Organization
Organization Name:MICHIANA HEMATOLOGY-ONCOLOGY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAFAT
Authorized Official - Middle Name:H
Authorized Official - Last Name:ANSARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-234-5123
Mailing Address - Street 1:100 E WAYNE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-2394
Mailing Address - Country:US
Mailing Address - Phone:574-334-5400
Mailing Address - Fax:574-334-5401
Practice Address - Street 1:5340 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1470
Practice Address - Country:US
Practice Address - Phone:574-237-1328
Practice Address - Fax:574-968-8488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing Site
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1176700001OtherDMERC
IN1560285OtherNCPDP
INCB5227OtherRRMC
IN100389430Medicaid
IN1176700003Medicare PIN
IN1560285OtherNCPDP