Basic Information
| Provider Information | |||||||||
| NPI: | 1326130725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACERNA | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | DANTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 SOUTH STATE STREET | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 W CHISHOLM ST | ||||||||
| Address2: | |||||||||
| City: | ALPENA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497071401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883567151 | ||||||||
| FaxNumber: | 9893568117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 4301059592 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | ME111595 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 4303114 | 05 | MI | MEDICAID | 4375200 | 05 | FL | MEDICAID | FT108Y | 01 | FL | MEDICARE | OTHER |