Basic Information
| Provider Information | |||||||||
| NPI: | 1871580142 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANCER CARE SPECIALISTS OF CENTRAL ILLINOIS, S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 W MCKINLEY AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625265858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178766600 | ||||||||
| FaxNumber: | 2178766606 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 W MCKINLEY AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625265858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178766600 | ||||||||
| FaxNumber: | 2178766606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | WADE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | LLOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2178766600 | ||||||||
| 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 | 042005607 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 332B00000X | 042005607 | IL | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207RX0202X | 042005607 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0005815189 | 01 | IL | BLUE CROSS/BLUE SHIELD OF | OTHER |