Provider Demographics
NPI:1750601456
Name:MICHIGAN HEMATOLOGY ONCOLOGY, PC
Entity type:Organization
Organization Name:MICHIGAN HEMATOLOGY ONCOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FARID
Authorized Official - Middle Name:T
Authorized Official - Last Name:FATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-620-9600
Mailing Address - Street 1:5680 BOW POINTE DR
Mailing Address - Street 2:STE 201
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5407
Mailing Address - Country:US
Mailing Address - Phone:248-620-9600
Mailing Address - Fax:248-620-9677
Practice Address - Street 1:5680 BOW POINTE DR
Practice Address - Street 2:STE 201
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5407
Practice Address - Country:US
Practice Address - Phone:248-620-9600
Practice Address - Fax:248-620-9677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFF072629207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104732771Medicaid
MIG96818Medicare UPIN
MI6345690001Medicare NSC