Provider Demographics
NPI:1720033046
Name:SILOAM LLC
Entity Type:Organization
Organization Name:SILOAM LLC
Other - Org Name:SOUTHERN ILLINOIS CANCER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:T
Authorized Official - Last Name:SANDFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-985-4000
Mailing Address - Street 1:171 TECHNOLOGY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-1530
Mailing Address - Country:US
Mailing Address - Phone:814-237-8627
Mailing Address - Fax:814-238-0083
Practice Address - Street 1:10286 FLEMING RD
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-3351
Practice Address - Country:US
Practice Address - Phone:918-985-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL455350OtherHEALTHLINK
IL10027422OtherIL BCBS
IL036104428Medicaid
IL643740Medicare ID - Type Unspecified