Basic Information
| Provider Information | |||||||||
| NPI: | 1164483913 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ILLINOIS CANCER SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25070 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475857000 | ||||||||
| FaxNumber: | 8472409093 | ||||||||
| Practice Location | |||||||||
| Address1: | 8915 W GOLF RD | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607145905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478279060 | ||||||||
| FaxNumber: | 8478277196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 06/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | HAKIMIAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8475857000 | ||||||||
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| 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 | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1619809 | 01 | IL | BCBS | OTHER |