Basic Information
| Provider Information | |||||||||
| NPI: | 1972553550 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARRISBURG CANCER CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15040 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477160040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124761367 | ||||||||
| FaxNumber: | 8124774153 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629462453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182525126 | ||||||||
| FaxNumber: | 6182520135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 09/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | RAZEK | ||||||||
| AuthorizedOfficialFirstName: | ALY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6182525126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MEDICAL DOCTOR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | CN1378 | 01 | IL | RR MEDICARE | OTHER | 3300262019 | 05 | IL | MEDICAID |