Basic Information
| Provider Information | |||||||||
| NPI: | 1184642555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH EASTERN MICHIGAN CANCER CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S. STATE ST. | ||||||||
| Address2: | 700 KMS, RM 519, RAD ONC | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475170 | ||||||||
| FaxNumber: | 7346155851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 W CHISHOLM ST | ||||||||
| Address2: | |||||||||
| City: | ALPENA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497071401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893567353 | ||||||||
| FaxNumber: | 9893568117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HALMAN | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7349364302 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 320Z41016 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |