Basic Information
| Provider Information | |||||||||
| NPI: | 1578515573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAGINAW RADIOTHERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4449 FASHION SQUARE BLVD | ||||||||
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| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486035217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897900007 | ||||||||
| FaxNumber: | 9897907547 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486012551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897900007 | ||||||||
| FaxNumber: | 9897907547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | YOUNG | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9897900007 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | CC9580 | 01 | MI | RR MEDICARE | OTHER |