Healthcare Provider Details

I. General information

NPI: 1750306692
Provider Name (Legal Business Name): CENTRAL ILLINOIS HEMATOLOGY ONCOLOGY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST 2204
SPRINGFIELD IL
62702-6700
US

IV. Provider business mailing address

747 N RUTLEDGE ST 2204
SPRINGFIELD IL
62702-6700
US

V. Phone/Fax

Practice location:
  • Phone: 217-525-2500
  • Fax: 217-525-9374
Mailing address:
  • Phone: 217-525-2500
  • Fax: 217-525-9374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. M SUE COFFEE
Title or Position: OFFICE MANAGER
Credential:
Phone: 800-292-4492