1992032809 NPI number — SOUTHERN ILLINOIS MEDICAL SERVICES, NFP

Table of content: (NPI 1992032809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992032809 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:
MEDICAL ARTS CLINIC
Provider Other Organization Name Type Code:
3
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:
1992032809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2015
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:
P.O. BOX 3988
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62902-3988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-684-2172
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 E SHAWNEE DR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MURPHYSBORO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62966-7071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-684-2172
Provider Business Practice Location Address Fax Number:
618-687-4480
Provider Enumeration Date:
11/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BUDDE
Authorized Official First Name:
REX
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
618-457-5200

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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