MEDICARE: MICHIANA HEMATOLOGY ONCOLOGY OF MICHIGAN, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207VX0201X	Gynecologic Oncology Physician
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	207RH0003X	Hematology & Oncology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0A11038	OTHER	MI	MIBCBS

General Provider Information

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

Provider Business Mailing Address
First Line	:	100 NAVARRE PL
Second Line	:	STE 6695
City	:	SOUTH BEND
State	:	IN
Zip	:	46601-1156
Country	:	US
Telephone Number	:	574-234-5123
Fax Number	:	574-237-1341

Provider Business Practice Location Address
First Line	:	4 LONGMEADOW DRIVE
Second Line	:	SUITE ONE
City	:	NILES
State	:	MI
Zip	:	49120
Country	:	US
Telephone Number	:	269-683-4153
Fax Number	:	269-683-4154

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAFAT H ANSARI
Credential	:	M.D.
Telephone Number	:	574-234-5123

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	10/13/2009

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