Provider Demographics
NPI:1407962442
Name:COMMUNITY CANCER CARE SPECIALISTS
Entity Type:Organization
Organization Name:COMMUNITY CANCER CARE SPECIALISTS
Other - Org Name:PAUL M DERDERIAN DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NOWAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-493-3435
Mailing Address - Street 1:1030 HARRINGTON ST
Mailing Address - Street 2:STE 301
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 HARRINGTON ST
Practice Address - Street 2:STE 301
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2967
Practice Address - Country:US
Practice Address - Phone:586-493-3440
Practice Address - Fax:586-493-3455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332900000X
MI51010095753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332900000XSuppliersNon-Pharmacy Dispensing Site
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2368430OtherOTHER ID NUMBER-COMMERCIAL NUMBER