Provider Demographics
NPI:1093796336
Name:INTER-COMMUNITY RADIATION ONCOLOGY SC
Entity Type:Organization
Organization Name:INTER-COMMUNITY RADIATION ONCOLOGY SC
Other - Org Name:SOUTH SUBURBAN CANCER CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYANT
Authorized Official - Middle Name:V
Authorized Official - Last Name:GINDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-799-9995
Mailing Address - Street 1:PO BOX 15040
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-0040
Mailing Address - Country:US
Mailing Address - Phone:812-962-6413
Mailing Address - Fax:812-471-9282
Practice Address - Street 1:17750 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2047
Practice Address - Country:US
Practice Address - Phone:708-799-9995
Practice Address - Fax:708-799-8129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCM3780OtherRR MEDICARE GROUP #
IL0031603263OtherBCBS OF IL
ILCM3780OtherRR MEDICARE GROUP #