Healthcare Provider Details

I. General information

NPI: 1124303466
Provider Name (Legal Business Name): MICHIANA HEMATOLOGY-ONCOLOGY P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 S MAIN ST SUITE 301
CROWN POINT IN
46307-3676
US

IV. Provider business mailing address

3975 WILLIAM RICHARDSON DR
SOUTH BEND IN
46628-9800
US

V. Phone/Fax

Practice location:
  • Phone: 219-661-1640
  • Fax: 219-661-8066
Mailing address:
  • Phone: 800-860-8100
  • Fax: 574-237-1341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number50002882A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number50002882A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number50002882A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number50002882A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number50002882A
License Number StateIN

VIII. Authorized Official

Name: RAFAT H. ANSARI
Title or Position: PRESIDENT
Credential: MD
Phone: 800-860-8100