Healthcare Provider Details

I. General information

NPI: 1487635314
Provider Name (Legal Business Name): SOUTHERN COOK RADIATION ONCOLOGY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 YORK ST SUITE M
BLUE ISLAND IL
60406-2411
US

IV. Provider business mailing address

PO BOX 379
ORLAND PARK IL
60462-0379
US

V. Phone/Fax

Practice location:
  • Phone: 708-396-0910
  • Fax: 708-388-4354
Mailing address:
  • Phone: 708-460-9836
  • Fax: 708-460-1117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GREGORIO M TOLENTINO JR.
Title or Position: OFFICER
Credential: MD
Phone: 708-396-0910