Basic Information
| Provider Information | |||||||||
| NPI: | 1508953746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ILLINOIS PHYSICIAN SERVICES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 23620 | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622230620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182229999 | ||||||||
| FaxNumber: | 6182229337 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 MEMORIAL DRIVE | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182229999 | ||||||||
| FaxNumber: | 6182229337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | TIBEREND | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING OFFICER SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6182229999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.