Provider Demographics
NPI:1093780371
Name:MCCI-MACOMB CANCER CENTER
Entity Type:Organization
Organization Name:MCCI-MACOMB CANCER CENTER
Other - Org Name:X-RAY TREATMENT CENTER, PC/MICHIGAN COMPREHENSIVE CANCER CTR. (MCCI)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FARIDEH
Authorized Official - Middle Name:R
Authorized Official - Last Name:BAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, JD
Authorized Official - Phone:248-338-0300
Mailing Address - Street 1:17435 HALL RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4061
Mailing Address - Country:US
Mailing Address - Phone:586-228-0299
Mailing Address - Fax:586-228-5918
Practice Address - Street 1:17435 HALL RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-4061
Practice Address - Country:US
Practice Address - Phone:586-228-0299
Practice Address - Fax:586-228-5918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID#