=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396019485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEASTERN MICHIGAN CANCER CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2012
-----------------------------------------------------
Last Update Date | 10/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 WEST CHISHOLM STREET SUITE 100
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-356-7597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 W CHISHOLM STREET
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-356-7597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | GEORGE SMART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 989-356-7597
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------