Provider Demographics
NPI:1235134461
Name:MICHIANA HEMATOLOGY ONCOLOGY OF MICHIGAN, P.C.
Entity Type:Organization
Organization Name:MICHIANA HEMATOLOGY ONCOLOGY OF MICHIGAN, 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 NAVARRE PL
Mailing Address - Street 2:STE 6695
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1156
Mailing Address - Country:US
Mailing Address - Phone:574-234-5123
Mailing Address - Fax:574-237-1341
Practice Address - Street 1:4 LONGMEADOW DRIVE
Practice Address - Street 2:SUITE ONE
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120
Practice Address - Country:US
Practice Address - Phone:269-683-4153
Practice Address - Fax:269-683-4154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A11038OtherMIBCBS
MI0A11038OtherMIBCBS
MI0N43780Medicare PIN
MI4815650001Medicare NSC