Provider Demographics
NPI:1881651529
Name:MICHIGAN RADIATION ONCOLOGY, PC
Entity Type:Organization
Organization Name:MICHIGAN RADIATION ONCOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-245-8334
Mailing Address - Street 1:PO BOX 1022
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49016-1022
Mailing Address - Country:US
Mailing Address - Phone:269-245-8334
Mailing Address - Fax:269-245-8335
Practice Address - Street 1:300 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3307
Practice Address - Country:US
Practice Address - Phone:269-245-8334
Practice Address - Fax:269-245-8335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010576992085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4434125Medicaid
MIP35860001OtherMI MEDICARE PTAN
MIP35860001OtherMI MEDICARE PTAN
MION56590Medicare ID - Type Unspecified