Basic Information
| Provider Information | |||||||||
| NPI: | 1700867496 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIATION ONCOLOGY OF KANKAKEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 379 | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604620379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087742970 | ||||||||
| FaxNumber: | 7084601117 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PROVENA WAY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BOURBONNAIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609144796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159372460 | ||||||||
| FaxNumber: | 8159372031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 07/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | ASAAD | ||||||||
| AuthorizedOfficialFirstName: | SALWA | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7087742970 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 | 046155057 | 01 | IL | BCBS IL GROUP# | OTHER |