Provider Demographics
NPI:1942559380
Name:AVENUE HEMATOLOGY AND ONCOLOGY LLC
Entity Type:Organization
Organization Name:AVENUE HEMATOLOGY AND ONCOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:KAMANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-968-4100
Mailing Address - Street 1:69045 M 62 STE B1ANDB2
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-9150
Mailing Address - Country:US
Mailing Address - Phone:574-968-4100
Mailing Address - Fax:874-968-4125
Practice Address - Street 1:69045 M 62 STE B1&B2
Practice Address - Street 2:
Practice Address - City:EDWARDSBURG
Practice Address - State:MI
Practice Address - Zip Code:49112-9150
Practice Address - Country:US
Practice Address - Phone:574-968-4100
Practice Address - Fax:574-968-4125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1050OtherMEDICARE PART B INDIANA
MIMI7766OtherMEDICARE PART B MICHIGAN