Provider Demographics
NPI:1013197698
Name:ST. MARY'S OF MICHIGAN
Entity Type:Organization
Organization Name:ST. MARY'S OF MICHIGAN
Other - Org Name:ST. MARY'S OF MICHIGAN BAD AXE ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-907-7509
Mailing Address - Street 1:4449 FASHION SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-5217
Mailing Address - Country:US
Mailing Address - Phone:989-790-0007
Mailing Address - Fax:
Practice Address - Street 1:1100 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9615
Practice Address - Country:US
Practice Address - Phone:989-790-0007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S OF MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N56480Medicare PIN