Basic Information
| Provider Information | |||||||||
| NPI: | 1053804443 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SIU PHYSICIANS & SURGEONS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SIU HEALTHCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19639 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175457876 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 610 N WESTGATE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172438455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2018 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | TURLEY | ||||||||
| AuthorizedOfficialFirstName: | JO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL STAFF COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2175457876 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.