1518343722 NPI number — BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY

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 1518343722 NPI number — BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
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:
SIU CENTER FOR FAMILY MEDICINE - NOLL
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:
1518343722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19670
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62794-9670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-545-8000
Provider Business Mailing Address Fax Number:
217-747-1351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5220 S 6TH STREET RD
Provider Second Line Business Practice Location Address:
SUITE 1500
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62703-5735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-545-8000
Provider Business Practice Location Address Fax Number:
217-747-1351
Provider Enumeration Date:
08/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WESLEY
Authorized Official First Name:
IRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/FQHC DIRECTOR
Authorized Official Telephone Number:
217-545-8000

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , 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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