Basic Information
| Provider Information | |||||||||
| NPI: | 1093796336 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTER-COMMUNITY RADIATION ONCOLOGY SC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH SUBURBAN CANCER CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15040 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477160040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129626413 | ||||||||
| FaxNumber: | 8124719282 | ||||||||
| Practice Location | |||||||||
| Address1: | 17750 KEDZIE AVE | ||||||||
| Address2: | |||||||||
| City: | HAZEL CREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604292047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087999995 | ||||||||
| FaxNumber: | 7087998129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GINDE | ||||||||
| AuthorizedOfficialFirstName: | JAYANT | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7087999995 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | CM3780 | 01 | IL | RR MEDICARE GROUP # | OTHER | 0031603263 | 01 | IL | BCBS OF IL | OTHER |