Basic Information
| Provider Information | |||||||||
| NPI: | 1588786339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ILLINOIS ONCOLOGY & HEMATOLOGY LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3008 CIVIC CIRCLE BLVD | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629595262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189931030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3008 CIVIC CIRCLE BLVD | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629595262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6073242340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | CUARTAS | ||||||||
| AuthorizedOfficialFirstName: | ALBERTO | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 6189931030 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036098622 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 10027291 | 01 | IL | BCBS OF ILLINOIS | OTHER | 036098622 | 05 | IL | MEDICAID |