Healthcare Provider Details

I. General information

NPI: 1760524995
Provider Name (Legal Business Name): ILLINOIS REGIONAL CANCER CENTER LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 HEALTH SERVICES DR
DEKALB IL
60115-9637
US

IV. Provider business mailing address

PO BOX 723
DEKALB IL
60115-0723
US

V. Phone/Fax

Practice location:
  • Phone: 815-756-4722
  • Fax: 815-756-4046
Mailing address:
  • Phone: 815-756-4722
  • Fax: 815-756-4046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036-061312
License Number StateIL

VIII. Authorized Official

Name: BHARATI D. BHATE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 815-756-4722