Provider Demographics
NPI:1871685149
Name:RADIATION MEDICINE INSTITUTE
Entity Type:Organization
Organization Name:RADIATION MEDICINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/RADIATION MEDICINE INST.
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-570-2590
Mailing Address - Street 1:9818 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60678-1098
Mailing Address - Country:US
Mailing Address - Phone:630-285-1530
Mailing Address - Fax:630-285-1490
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:814-570-2590
Practice Address - Fax:847-570-1878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-083680174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL970680Medicare ID - Type UnspecifiedGROUP COOK COUNTY ID