Healthcare Provider Details

I. General information

NPI: 1427051200
Provider Name (Legal Business Name): JOSEPH MIRRO JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N PARK ST WEST MICHIGAN CANCER CENTER
KALAMAZOO MI
49007-3731
US

IV. Provider business mailing address

200 N PARK ST WEST MICHIGAN CANCER CENTER
KALAMAZOO MI
49007-3731
US

V. Phone/Fax

Practice location:
  • Phone: 269-910-6555
  • Fax: 269-384-8610
Mailing address:
  • Phone: 269-910-6555
  • Fax: 269-384-8610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number13553
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number4301100173
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: