Healthcare Provider Details

I. General information

NPI: 1003955485
Provider Name (Legal Business Name): MICHIANA HEMATOLOGY-ONCOLOGY P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 HOLY CROSS PKWY
MISHAWAKA IN
46545-1470
US

IV. Provider business mailing address

PO BOX 746092
ATLANTA GA
30374-6092
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-1328
  • Fax: 574-968-8488
Mailing address:
  • Phone: 574-237-1328
  • Fax: 574-237-1348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: BILAL ANSARI
Title or Position: PRESIDENT
Credential: MD
Phone: 574-261-0794