Provider Demographics
NPI:1447261730
Name:WEST MICHIGAN CANCER CENTER
Entity type:Organization
Organization Name:WEST MICHIGAN CANCER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO/CMO
Authorized Official - Prefix:DR
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 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8419
Mailing Address - Fax:269-341-8743
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:269-382-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST MICHIGAN CANCER CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-11
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RX0202X, 207VX0201X, 363A00000X, 363L00000X
MI2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2430038OtherUHC
MI0C91143OtherBCBSM
MI2430038OtherUHC
MI0N66670Medicare PIN