Healthcare Provider Details

I. General information

NPI: 1801829395
Provider Name (Legal Business Name): NOMC/MACNEAL RADIATION THERAPY JOINT VENTURE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/21/2022
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 34TH ST
BERWYN IL
60402-5591
US

IV. Provider business mailing address

PO BOX 94
HIAWATHA IA
52233-0094
US

V. Phone/Fax

Practice location:
  • Phone: 708-484-0011
  • Fax: 708-484-0549
Mailing address:
  • Phone: 319-826-3763
  • Fax: 888-609-6019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. ROGER S KRUEGER
Title or Position: GROUP ADMINISTRATOR
Credential:
Phone: 630-734-9560