1780609578 NPI number — SOUTHERN ILLINOIS HEALTH CARE FOUNDATION, INC.

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 1780609578 NPI number — SOUTHERN ILLINOIS HEALTH CARE FOUNDATION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN ILLINOIS HEALTH CARE FOUNDATION, INC.
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:
6
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:
1780609578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8080 STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST SAINT LOUIS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62203-1808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-397-3303
Provider Business Mailing Address Fax Number:
618-397-7802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 S 3RD ST STE 103&104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-233-5480
Provider Business Practice Location Address Fax Number:
618-233-4790
Provider Enumeration Date:
07/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCCULLEY
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
618-332-0783

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 732740 . This is a "WPS MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".