Basic Information
| Provider Information | |||||||||
| NPI: | 1215578109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19639 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175457876 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 S 24TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623014446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172249484 | ||||||||
| FaxNumber: | 2172247950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | WESLEY | ||||||||
| AuthorizedOfficialFirstName: | IRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2175458000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.