Healthcare Provider Details

I. General information

NPI: 1467031013
Provider Name (Legal Business Name): CANCER GENOMIC CONSULTANTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 HEATHERLEA CT
CANTON MI
48188-6238
US

IV. Provider business mailing address

1150 HEATHERLEA CT
CANTON MI
48188-6238
US

V. Phone/Fax

Practice location:
  • Phone: 734-765-4282
  • Fax:
Mailing address:
  • Phone: 734-765-4282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID HALVERSON
Title or Position: CEO
Credential: MD
Phone: 734-765-4282