Basic Information
| Provider Information | |||||||||
| NPI: | 1649343864 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 8472400622 | ||||||||
| Practice Location | |||||||||
| Address1: | 8915 W GOLF RD | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607145905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479543480 | ||||||||
| FaxNumber: | 8478271574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 10/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | PARTLOW | ||||||||
| AuthorizedOfficialFirstName: | GAIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8475857050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 054014868 | IL | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1619809 | 01 | IL | BLUECROSS BLUESHIELD IL | OTHER |