Provider Demographics
NPI:1417985011
Name:WESTERN ILLINOIS CANCER TREATMENT CENTER
Entity Type:Organization
Organization Name:WESTERN ILLINOIS CANCER TREATMENT CENTER
Other - Org Name:INTERCOMMUNITY CANCER CENTER OF WESTERN ILLINOIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-344-2831
Mailing Address - Street 1:450 MAYO DR
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1211
Mailing Address - Country:US
Mailing Address - Phone:309-344-2831
Mailing Address - Fax:309-344-2014
Practice Address - Street 1:450 MAYO DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1211
Practice Address - Country:US
Practice Address - Phone:309-344-2831
Practice Address - Fax:309-344-2014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360772702471R0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471R0002XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiation TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
007799OtherHEALTH ALLIANCE
IL014885OtherHEALTH ALLIANCE INS.
04815059OtherBLUE CROSS BLUE SHIELD
ILCM5868OtherRAILROAD MEDICARE
IL768730Medicare PIN