MEDICARE: WESTERN ILLINOIS CANCER TREATMENT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2471R0002X	Radiation Therapy Radiologic Technologist	036077270	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	CM5868	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007799	OTHER		HEALTH ALLIANCE
2	014885	OTHER	IL	HEALTH ALLIANCE INS.
3	04815059	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1417985011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN ILLINOIS CANCER TREATMENT CENTER

Provider Business Mailing Address
First Line	:	450 MAYO DR
Second Line	:
City	:	GALESBURG
State	:	IL
Zip	:	61401-1211
Country	:	US
Telephone Number	:	309-344-2831
Fax Number	:	309-344-2014

Provider Business Practice Location Address
First Line	:	450 MAYO DR
Second Line	:
City	:	GALESBURG
State	:	IL
Zip	:	61401-1211
Country	:	US
Telephone Number	:	309-344-2831
Fax Number	:	309-344-2014

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. WARREN M WILKINS
Credential	:	M.D.
Telephone Number	:	309-344-2831

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	04/30/2008

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Directions to “WESTERN ILLINOIS CANCER TREATMENT CENTER ” Practice Location

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