Basic Information
| Provider Information | |||||||||
| NPI: | 1093801797 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN ILLINOIS HOSPITAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEMORIAL HOSPITAL OF CARBONDALE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1239 E. MAIN | ||||||||
| Address2: | PO BOX 3988 | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 405 W JACKSON | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARTKE | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE DIRECTOR, PATIENT FINANCI | ||||||||
| AuthorizedOfficialTelephone: | 6184575200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA, CHFP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0000513 | IL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0000513 | 01 | IL | STATE OF IL LICENSE NUMBE | OTHER |