Basic Information
| Provider Information | |||||||||
| NPI: | 1255880647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC. | ||||||||
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| OtherOrganizationName: | ILLINI FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2041 GOOSE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SAUGET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622062822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183320953 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2900 FRANK SCOTT PKWY W | ||||||||
| Address2: | SUITE 980 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622235000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183973303 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2016 | ||||||||
| LastUpdateDate: | 09/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCCULLEY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6183320694 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.