Provider Demographics
NPI:1851561773
Name:NORTHERN ONCOLOGY SERVICES PLLC
Entity Type:Organization
Organization Name:NORTHERN ONCOLOGY SERVICES PLLC
Other - Org Name:MEDICAL SPECIALTY ASSOCIATES PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PAWL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-456-8115
Mailing Address - Street 1:515 MICHIGAN ST NE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5721
Mailing Address - Country:US
Mailing Address - Phone:616-456-8115
Mailing Address - Fax:616-456-1079
Practice Address - Street 1:515 MICHIGAN ST NE
Practice Address - Street 2:SUITE 301
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5721
Practice Address - Country:US
Practice Address - Phone:616-456-8115
Practice Address - Fax:616-456-1079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038152174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2991200Medicaid
MI0M84460Medicare PIN
MI2991200Medicaid
MIM84460001Medicare PIN