Basic Information
| Provider Information | |||||||||
| NPI: | 1447318050 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ILLINOIS RADIATION ONCOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 WEST MAIN STREET | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629012604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185293159 | ||||||||
| FaxNumber: | 6183519909 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 PIN OAK DR | ||||||||
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| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629181600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189853333 | ||||||||
| FaxNumber: | 6189851315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6189853333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 036078040 | 05 | IL | MEDICAID |