Provider Demographics
NPI:1467467803
Name:MID-ILLINOIS HEMATOLOGY ONCOLOGY ASSOCIATES LTD
Entity Type:Organization
Organization Name:MID-ILLINOIS HEMATOLOGY ONCOLOGY ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAMERN
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIRATANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-452-9701
Mailing Address - Street 1:407 E VERNON AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1606 HUNT DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2192
Practice Address - Country:US
Practice Address - Phone:309-452-9701
Practice Address - Fax:309-454-1957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6020810001Medicare NSC