Healthcare Provider Details

I. General information

NPI: 1952477028
Provider Name (Legal Business Name): MT VERNON RADIATION THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4117 VETERANS MEMORIAL DR
MOUNT VERNON IL
62864-6262
US

IV. Provider business mailing address

PO BOX 504229
SAINT LOUIS MO
63150-0001
US

V. Phone/Fax

Practice location:
  • Phone: 618-241-1827
  • Fax:
Mailing address:
  • Phone: 618-241-1827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. RICHARD HUNTINGTON
Title or Position: VICE PRESIDENT BUSINESS DEVELOPMENT
Credential:
Phone: 618-241-2204