Basic Information
| Provider Information | |||||||||
| NPI: | 1376588871 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC. | ||||||||
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| OtherOrganizationName: | BELLEVILLE PEDIATRIC & ADOLESCENT HEALTH CENTER | ||||||||
| 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: | 6183322487 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 FRANK SCOTT PKWY W | ||||||||
| Address2: | SUITE 950 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622235000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182333205 | ||||||||
| FaxNumber: | 6182331407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCCULLEY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6183320694 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 732740 | 01 | IL | WPS MEDICARE | OTHER |