Healthcare Provider Details

I. General information

NPI: 1144327487
Provider Name (Legal Business Name): NORTHERN ILLINOIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KIRK AND PINE RD
BATAVIA IL
60510
US

IV. Provider business mailing address

307 LOWDEN HALL NIU OUTREACH
DEKALB IL
60115-3080
US

V. Phone/Fax

Practice location:
  • Phone: 630-840-3865
  • Fax:
Mailing address:
  • Phone: 815-753-0924
  • Fax: 815-753-0666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN PETERS
Title or Position: PRESIDENT
Credential: PHD
Phone: 815-753-9500