Basic Information
| Provider Information | |||||||||
| NPI: | 1487635314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN COOK RADIATION ONCOLOGY LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 379 | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604620379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084609836 | ||||||||
| FaxNumber: | 7084601117 | ||||||||
| Practice Location | |||||||||
| Address1: | 2310 YORK ST | ||||||||
| Address2: | SUITE M | ||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604062411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083960910 | ||||||||
| FaxNumber: | 7083884354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 07/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | TOLENTINO | ||||||||
| AuthorizedOfficialFirstName: | GREGORIO | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7083960910 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| 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 | CL9637 | 01 | RR MEDICARE GR | OTHER | 1617459 | 01 | IL | BCBS IL GR # | OTHER |