Basic Information
| Provider Information | |||||||||
| NPI: | 1376588848 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SALEM MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8080 STATE ST | ||||||||
| Address2: | |||||||||
| City: | EAST SAINT LOUIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622031808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183973303 | ||||||||
| FaxNumber: | 6183977802 | ||||||||
| Practice Location | |||||||||
| Address1: | 1275 HAWTHORN RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628811028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185484545 | ||||||||
| FaxNumber: | 6185484577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCCULLEY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6183320783 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 201518 | 01 | IL | WPS MEDICARE GROUP NUMBER | OTHER |