Provider Demographics
NPI:1730506510
Name:WEST MICHIGAN CANCER CENTER
Entity type:Organization
Organization Name:WEST MICHIGAN CANCER CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-382-2500
Mailing Address - Street 1:200 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3731
Mailing Address - Country:US
Mailing Address - Phone:269-384-8626
Mailing Address - Fax:269-373-7478
Practice Address - Street 1:200 N PARK ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3731
Practice Address - Country:US
Practice Address - Phone:269-384-8626
Practice Address - Fax:269-373-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-18
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010103743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1730506510Medicaid
2144774OtherPK