Provider Demographics
NPI:1679614424
Name:GRAND RAPIDS RADIATION ONCOLOGY PC
Entity type:Organization
Organization Name:GRAND RAPIDS RADIATION ONCOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:KANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-897-0995
Mailing Address - Street 1:6935 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:616-897-0995
Mailing Address - Fax:616-897-0986
Practice Address - Street 1:250 CHERRY
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-752-6218
Practice Address - Fax:616-774-8960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D11351OtherBCBSM
MI1005578OtherCHP
MI0M02130Medicare ID - Type UnspecifiedPROVIDER ID