1417985011 NPI number — WESTERN ILLINOIS CANCER TREATMENT CENTER

Table of content: (NPI 1417985011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417985011 NPI number — WESTERN ILLINOIS CANCER TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN ILLINOIS CANCER TREATMENT CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INTERCOMMUNITY CANCER CENTER OF WESTERN ILLINOIS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417985011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 MAYO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALESBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61401-1211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-344-2831
Provider Business Mailing Address Fax Number:
309-344-2014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 MAYO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALESBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61401-1211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-344-2831
Provider Business Practice Location Address Fax Number:
309-344-2014
Provider Enumeration Date:
06/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILKINS
Authorized Official First Name:
WARREN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
309-344-2831

Provider Taxonomy Codes

  • Taxonomy code: 2471R0002X , with the licence number:  036077270 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 007799 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 014885 . This is a "HEALTH ALLIANCE INS." identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 04815059 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: CM5868 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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