Provider Demographics
NPI:1447318050
Name:SOUTHERN ILLINOIS RADIATION ONCOLOGY LLC
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS RADIATION ONCOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-985-3333
Mailing Address - Street 1:600 WEST MAIN STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2604
Mailing Address - Country:US
Mailing Address - Phone:618-529-3159
Mailing Address - Fax:618-351-9909
Practice Address - Street 1:1400 PIN OAK DR
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1600
Practice Address - Country:US
Practice Address - Phone:618-985-3333
Practice Address - Fax:618-985-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078040Medicaid