Basic Information
| Provider Information | |||||||||
| NPI: | 1811082886 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHO | ||||||||
| FirstName: | SEONG | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 W MCKINLEY AVE | ||||||||
| Address2: | STE 1 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 92526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178766600 | ||||||||
| FaxNumber: | 2178766606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 HEALTH CENTER DRIVE | ||||||||
| Address2: | RADIATION DEPT. | ||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619380372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172582525 | ||||||||
| FaxNumber: | 2172582249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 01/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 036112160 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 207R00000X | 036112160 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036112160 | 05 | IL | MEDICAID |