Healthcare Provider Details

I. General information

NPI: 1093780371
Provider Name (Legal Business Name): MCCI-MACOMB CANCER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17435 HALL RD
MACOMB MI
48044-4061
US

IV. Provider business mailing address

17435 HALL RD
MACOMB MI
48044-4061
US

V. Phone/Fax

Practice location:
  • Phone: 586-228-0299
  • Fax: 586-228-5918
Mailing address:
  • Phone: 586-228-0299
  • Fax: 586-228-5918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: FARIDEH R. BAGNE
Title or Position: CEO
Credential: PH.D., J.D.
Phone: 248-338-0300