Basic Information
| Provider Information | |||||||||
| NPI: | 1821055500 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARQUETTE GENERAL HOSPITAL, INC. | ||||||||
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| OtherOrganizationName: | UP HEMATOLOGY ONCOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4602 DEPT | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601220021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062253922 | ||||||||
| FaxNumber: | 9062254527 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 W FAIR AVE | ||||||||
| Address2: | SUITE 332 | ||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498552675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062253922 | ||||||||
| FaxNumber: | 9062254527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 01/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | MULLER | ||||||||
| AuthorizedOfficialFirstName: | A. GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9062254821 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207ZH0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Hematology | 2085R0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 4704207327 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 4704207327 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 207RH0003X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
ID Information
| ID | Type | State | Issuer | Description | CH3316 | 01 | MI | RAILROAD MEDICARE | OTHER | 0E21002 | 01 | MI | BCBS GROUP | OTHER | CB4751 | 01 | MI | RAILROAD MEDICARE | OTHER | CH6298 | 01 | MI | RAILROAD MEDICARE | OTHER |