Healthcare Provider Details

I. General information

NPI: 1316869746
Provider Name (Legal Business Name): CANYON CREST RADIATION ONCOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4931 VENTURE DRIVE
PERU IL
61345
US

IV. Provider business mailing address

4931 VENTURE DRIVE
PERU IL
61345
US

V. Phone/Fax

Practice location:
  • Phone: 779-345-2945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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. ROBERT THEODORE WOODBURN III
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 219-741-1713