1770656837 NPI number — SOUTHERN ILLINOIS MEDICAL SERVICES NFP

Table of content: (NPI 1770656837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770656837 NPI number — SOUTHERN ILLINOIS MEDICAL SERVICES NFP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN ILLINOIS MEDICAL SERVICES NFP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SIH MEDICAL GROUP
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770656837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1239 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62901-3175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-457-5200
Provider Business Mailing Address Fax Number:
618-529-0568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1239 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-457-5200
Provider Business Practice Location Address Fax Number:
618-549-5128
Provider Enumeration Date:
11/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCHAEFER
Authorized Official First Name:
PHIL
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VP
Authorized Official Telephone Number:
618-457-5200

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3932056 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".