Basic Information
| Provider Information | |||||||||
| NPI: | 1003857061 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL ILLINOIS RADIATION ONCOLOGY PHYSICIANS, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 SW MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616021107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096718749 | ||||||||
| FaxNumber: | 3096718740 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 NE GLEN OAK AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616360001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096725700 | ||||||||
| FaxNumber: | 3096712774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | SWAMINATHAN | ||||||||
| AuthorizedOfficialFirstName: | REVATHI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3096718749 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | DE7037 | 01 | RAILROAD GROUP NUMBER | OTHER |