Provider Demographics
NPI:1184272817
Name:BLUE WATER RAD ONC, LLC
Entity type:Organization
Organization Name:BLUE WATER RAD ONC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CATHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-216-1833
Mailing Address - Street 1:2601 ELECTRIC AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6587
Mailing Address - Country:US
Mailing Address - Phone:810-216-2902
Mailing Address - Fax:810-216-3025
Practice Address - Street 1:2601 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6587
Practice Address - Country:US
Practice Address - Phone:810-216-2902
Practice Address - Fax:810-216-3025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty