Healthcare Provider Details

I. General information

NPI: 1871580142
Provider Name (Legal Business Name): CANCER CARE SPECIALISTS OF CENTRAL ILLINOIS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/31/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W MCKINLEY AVE SUITE 1
DECATUR IL
62526-5858
US

IV. Provider business mailing address

210 W MCKINLEY AVE SUITE 1
DECATUR IL
62526-5858
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-6600
  • Fax: 217-876-6606
Mailing address:
  • Phone: 217-876-6600
  • Fax: 217-876-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number042005607
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number042005607
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number042005607
License Number StateIL

VIII. Authorized Official

Name: DR. JUSTIN D FLOYD
Title or Position: PRESIDENT
Credential: MD
Phone: 618-416-7970