Provider Demographics
NPI:1760524995
Name:ILLINOIS REGIONAL CANCER CENTER LLP
Entity Type:Organization
Organization Name:ILLINOIS REGIONAL CANCER CENTER LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BHARATI
Authorized Official - Middle Name:D
Authorized Official - Last Name:BHATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-756-4722
Mailing Address - Street 1:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-0723
Mailing Address - Country:US
Mailing Address - Phone:815-756-4722
Mailing Address - Fax:815-756-4046
Practice Address - Street 1:10 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9637
Practice Address - Country:US
Practice Address - Phone:815-756-4722
Practice Address - Fax:815-756-4046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-061312174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1962496034OtherPROVIDER NPI NUMBER
IL036-061312Medicaid
ILE35531Medicare UPIN
IL210339Medicare PIN