Provider Demographics
NPI:1124303466
Name:MICHIANA HEMATOLOGY-ONCOLOGY P C
Entity type:Organization
Organization Name:MICHIANA HEMATOLOGY-ONCOLOGY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAFAT
Authorized Official - Middle Name:H
Authorized Official - Last Name:ANSARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-860-8100
Mailing Address - Street 1:3975 WILLIAM RICHARDSON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9800
Mailing Address - Country:US
Mailing Address - Phone:800-860-8100
Mailing Address - Fax:574-237-1341
Practice Address - Street 1:1205 S MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-3676
Practice Address - Country:US
Practice Address - Phone:219-661-1640
Practice Address - Fax:219-661-8066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50002882A207VX0201X, 2085R0001X, 332900000X, 332B00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1176700002Medicare PIN