Basic Information
| Provider Information | |||||||||
| NPI: | 1194206367 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ILLINOIS CANCER SPECIALISTS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ILLINOIS CANCER SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 360 STATION DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600147978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153630066 | ||||||||
| FaxNumber: | 8153852812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2018 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | HAKIMIAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8475857000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.