Healthcare Provider Details

I. General information

NPI: 1235134461
Provider Name (Legal Business Name): MICHIANA HEMATOLOGY ONCOLOGY OF MICHIGAN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 LONGMEADOW DRIVE SUITE ONE
NILES MI
49120
US

IV. Provider business mailing address

100 NAVARRE PL STE 6695
SOUTH BEND IN
46601-1156
US

V. Phone/Fax

Practice location:
  • Phone: 269-683-4153
  • Fax: 269-683-4154
Mailing address:
  • Phone: 574-234-5123
  • Fax: 574-237-1341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: RAFAT H ANSARI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 574-234-5123