Provider Demographics
NPI:1528057692
Name:DOWNRIVER CANCER CENTER
Entity type:Organization
Organization Name:DOWNRIVER CANCER CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GROUP PRACTICE DIR.
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPOSITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-916-2803
Mailing Address - Street 1:19675 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1021
Mailing Address - Country:US
Mailing Address - Phone:734-479-3311
Mailing Address - Fax:734-479-8009
Practice Address - Street 1:19675 ALLEN RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1021
Practice Address - Country:US
Practice Address - Phone:734-479-3311
Practice Address - Fax:734-479-8009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4026082085R0001X
MI0650572085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3156435Medicaid
MI4476493OtherGREAT LAKES HEALTH PLAN
MIOM11130OtherHEALTH ALLIANCE PLAN
MI018870OtherMIDWEST HEALTH PLAN
MI320H210170OtherBCBS
MI4476493Medicaid
MI3156435Medicaid
MI4476493Medicaid
MI320H210170OtherBCBS