1912347485 NPI number — SOUTHERNMOST ILLINOIS COMMUNITY HEALTH IMPROVEMENT CORPORATION

Table of content: (NPI 1912347485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912347485 NPI number — SOUTHERNMOST ILLINOIS COMMUNITY HEALTH IMPROVEMENT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERNMOST ILLINOIS COMMUNITY HEALTH IMPROVEMENT CORPORATION
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:
CAIRO DIAGNOSTIC CENTER LABORATORY
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:
1912347485
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13289 KESSLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAIRO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62914-3101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-734-1500
Provider Business Mailing Address Fax Number:
618-734-9152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13289 KESSLER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAIRO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62914-3101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-734-1500
Provider Business Practice Location Address Fax Number:
618-734-9152
Provider Enumeration Date:
06/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BERNSTEIN
Authorized Official First Name:
FREDERICK
Authorized Official Middle Name:
L
Authorized Official Title or Position:
C.E.O.
Authorized Official Telephone Number:
618-457-0450

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14D0436489 . This is a "CLIA#" identifier . This identifiers is of the category "OTHER".




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