Basic Information
| Provider Information | |||||||||
| NPI: | 1730392424 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDWESTERN REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CANCER TEATMENT CENTERS OF AMERICA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 ELISHA AVE | ||||||||
| Address2: | |||||||||
| City: | ZION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600992676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478724561 | ||||||||
| FaxNumber: | 8478726176 | ||||||||
| Practice Location | |||||||||
| Address1: | 2520 ELISHA AVE | ||||||||
| Address2: | |||||||||
| City: | ZION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600992676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478724561 | ||||||||
| FaxNumber: | 8478726176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARAVILLA | ||||||||
| AuthorizedOfficialFirstName: | STANISLAV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REHABILITATION SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8478726232 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.