MEDICARE: DOWNRIVER CANCER CENTER

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	402608	MI
2	2085R0001X	Radiation Oncology Physician	065057	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4476493	OTHER	MI	GREAT LAKES HEALTH PLAN
3	OM11130	OTHER	MI	HEALTH ALLIANCE PLAN
4	018870	OTHER	MI	MIDWEST HEALTH PLAN
5	320H210170	OTHER	MI	BCBS
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528057692
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOWNRIVER CANCER CENTER

Provider Business Mailing Address
First Line	:	19675 ALLEN RD
Second Line	:
City	:	BROWNSTOWN TWP
State	:	MI
Zip	:	48183-1021
Country	:	US
Telephone Number	:	734-479-3311
Fax Number	:	734-479-8009

Provider Business Practice Location Address
First Line	:	19675 ALLEN RD
Second Line	:
City	:	BROWNSTOWN TWP
State	:	MI
Zip	:	48183-1021
Country	:	US
Telephone Number	:	734-479-3311
Fax Number	:	734-479-8009

Authorized Official
Title or Position	:	GROUP PRACTICE DIR.
Name	:	MRS. AMY ESPOSITO
Credential	:
Telephone Number	:	313-916-2803

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	05/29/2013

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1508862590 — VICKI ANTON ANTHENS DPM PC
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Directions to “DOWNRIVER CANCER CENTER ” Practice Location

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