Provider Demographics
NPI:1386644995
Name:NORTHERN ILLINOIS CANCER TREATMENT CENTER
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS CANCER TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-284-1111
Mailing Address - Street 1:327 IL ROUTE 2
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-9118
Mailing Address - Country:US
Mailing Address - Phone:815-284-1111
Mailing Address - Fax:815-284-2306
Practice Address - Street 1:327 IL ROUTE 2
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9118
Practice Address - Country:US
Practice Address - Phone:815-284-1111
Practice Address - Fax:815-284-2306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05215222OtherBLUE SHIELD PROVIDER NUMB
IL210699Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER