1578746228 NPI number — SOUTHERN ILLINOIS MEDICAL PLAZA SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578746228 NPI number — SOUTHERN ILLINOIS MEDICAL PLAZA SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN ILLINOIS MEDICAL PLAZA SC
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:
Provider Other Organization Name Type Code:
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:
1578746228
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2250 REED STATION PKWY
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-529-1943
Provider Business Mailing Address Fax Number:
618-549-2975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 REED STATION PKWY
Provider Second Line Business Practice Location Address:
STE 305
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-3304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-529-1943
Provider Business Practice Location Address Fax Number:
618-549-2975
Provider Enumeration Date:
12/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BARRETT
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-529-1943

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036093859 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 038007699 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03932090 . This is a "BCBS OF IL GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".