Provider Demographics
NPI:1144327487
Name:NORTHERN ILLINOIS UNIVERSITY
Entity type:Organization
Organization Name:NORTHERN ILLINOIS UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:815-753-9500
Mailing Address - Street 1:307 LOWDEN HALL
Mailing Address - Street 2:NIU OUTREACH
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3080
Mailing Address - Country:US
Mailing Address - Phone:815-753-0924
Mailing Address - Fax:815-753-0666
Practice Address - Street 1:KIRK AND PINE RD
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510
Practice Address - Country:US
Practice Address - Phone:630-840-3865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN ILLINOIS UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213157Medicare PIN