=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982857827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACOMB ONCOLOGY INSTITUTE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2008
-----------------------------------------------------
Last Update Date | 02/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 EAST GRANT STREET
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-836-8400
-----------------------------------------------------
Fax | 309-836-8440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 483
-----------------------------------------------------
City | LITCHFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62056-0483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-324-1100
-----------------------------------------------------
Fax | 217-324-1103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JACQUELINE LAM YUEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-324-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------