1861909509 NPI number — SOUTHERN ILLINOIS NEUROPSYCHOLOGY LLC

Table of content: (NPI 1861909509)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861909509 NPI number — SOUTHERN ILLINOIS NEUROPSYCHOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN ILLINOIS NEUROPSYCHOLOGY 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:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1861909509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 OAK DR UNIT 352
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62062-7026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-391-4021
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 S STATE ROUTE 157
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDWARDSVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-391-4021
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2018

Additional Information

Authorized Official

Authorized Official Last Name:
RUPPERT
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
618-391-4021

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  071009269 , 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)





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