Provider Demographics
NPI:1710952775
Name:MICHIGAN INSTITUTE FOR RADIATION ONCOLOGY/MIRO CANCER CENTER
Entity Type:Organization
Organization Name:MICHIGAN INSTITUTE FOR RADIATION ONCOLOGY/MIRO CANCER CENTER
Other - Org Name:
Other - Org Type:
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 1:70 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2755
Mailing Address - Country:US
Mailing Address - Phone:248-338-0300
Mailing Address - Fax:248-338-0663
Practice Address - Street 1:70 FULTON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-2755
Practice Address - Country:US
Practice Address - Phone:248-338-0300
Practice Address - Fax:248-338-0663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID#