1720033046 NPI number — SILOAM LLC

Table of content: (NPI 1720033046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720033046 NPI number — SILOAM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SILOAM LLC
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:
SOUTHERN ILLINOIS CANCER CENTER
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:
1720033046
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
171 TECHNOLOGY DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BOALSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16827-1530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-237-8627
Provider Business Mailing Address Fax Number:
814-238-0083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10286 FLEMING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARTERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62918-3351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-985-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SANDFORD
Authorized Official First Name:
JACK
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
618-985-4000

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , 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: 455350 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 10027422 . This is a "IL BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036104428 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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