Basic Information
| Provider Information | |||||||||
| NPI: | 1346353661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ILLINOIS ANESTHESIOLOGY LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4227 LINCOLNSHIRE DRIVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182422317 | ||||||||
| FaxNumber: | 6182429710 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 N 12TH STREET | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628642857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182411108 | ||||||||
| FaxNumber: | 6182413805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EATON | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6182411108 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 42617784 | IL | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | 42617784 | IL | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207LP2900X | 42617784 | IL | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.