Basic Information
Provider Information | |||||||||
NPI: | 1467482968 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILY CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8080 STATE ST | ||||||||
Address2: |   | ||||||||
City: | EAST SAINT LOUIS | ||||||||
State: | IL | ||||||||
PostalCode: | 622031808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183973303 | ||||||||
FaxNumber: | 6183977802 | ||||||||
Practice Location | |||||||||
Address1: | 2071 GOOSE LAKE RD | ||||||||
Address2: |   | ||||||||
City: | SAUGET | ||||||||
State: | IL | ||||||||
PostalCode: | 622062822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183325369 | ||||||||
FaxNumber: | 6183379482 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 10/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCULLEY | ||||||||
AuthorizedOfficialFirstName: | LARRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6183320783 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 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 GROUP NUMBER | OTHER |