MEDICARE: MIRO-MADISON HEIGHTS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician

General Provider Information

NPI Number	:	1336114735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIRO-MADISON HEIGHTS

Provider Business Mailing Address
First Line	:	70 FULTON ST
Second Line	:
City	:	PONTIAC
State	:	MI
Zip	:	48341-2755
Country	:	US
Telephone Number	:	248-338-0300
Fax Number	:	248-338-0663

Provider Business Practice Location Address
First Line	:	30365 DEQUINDRE RD
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-2200
Country	:	US
Telephone Number	:	248-589-5000
Fax Number	:	248-589-5006

Authorized Official
Title or Position	:	CEO
Name	:	FARIDEH R. BAGNE
Credential	:	PH.D., J.D.
Telephone Number	:	248-338-0300

Provider Enumeration Date	:	02/20/2006
Last Update Date	:	08/22/2020

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Directions to “MIRO-MADISON HEIGHTS ” Practice Location

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