Provider Demographics
NPI:1619054160
Name:BLUE WATER ONCOLOGY PC
Entity Type:Organization
Organization Name:BLUE WATER ONCOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHEFFLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-985-1670
Mailing Address - Street 1:2605 ELECTRIC AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6590
Mailing Address - Country:US
Mailing Address - Phone:810-985-1670
Mailing Address - Fax:810-982-9180
Practice Address - Street 1:2605 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6590
Practice Address - Country:US
Practice Address - Phone:810-985-1670
Practice Address - Fax:810-982-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054609207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G41029OtherBCBS COMMON PROVIDER CODE
MICG7803OtherRAILROAD MEDICARE
MICG7803OtherRAILROAD MEDICARE