Provider Demographics
NPI:1487635314
Name:SOUTHERN COOK RADIATION ONCOLOGY LTD
Entity type:Organization
Organization Name:SOUTHERN COOK RADIATION ONCOLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:TOLENTINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:708-396-0910
Mailing Address - Street 1:PO BOX 379
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-0379
Mailing Address - Country:US
Mailing Address - Phone:708-460-9836
Mailing Address - Fax:708-460-1117
Practice Address - Street 1:2310 YORK ST
Practice Address - Street 2:SUITE M
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2411
Practice Address - Country:US
Practice Address - Phone:708-396-0910
Practice Address - Fax:708-388-4354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CL9637OtherRR MEDICARE GR
IL1617459OtherBCBS IL GR #
211514Medicare PIN