Provider Demographics
NPI:1801829395
Name:NOMC/MACNEAL RADIATION THERAPY JOINT VENTURE, LLC
Entity Type:Organization
Organization Name:NOMC/MACNEAL RADIATION THERAPY JOINT VENTURE, LLC
Other - Org Name:D.B.A.-BERWYN RADIATION ONCOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GROUP ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:S
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-734-9560
Mailing Address - Street 1:PO BOX 94
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:IA
Mailing Address - Zip Code:52233-0094
Mailing Address - Country:US
Mailing Address - Phone:319-826-3763
Mailing Address - Fax:888-609-6019
Practice Address - Street 1:6801 34TH ST
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-5591
Practice Address - Country:US
Practice Address - Phone:708-484-0011
Practice Address - Fax:708-484-0549
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NUCLEAR ONCOLOGY SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-08
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
ILDE8968OtherRAILROAD MEDICARE PIN
ILDE8968OtherRAILROAD MEDICARE PIN