Basic Information
| Provider Information | |||||||||
| NPI: | 1528126257 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ILLINOIS HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 S 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189422171 | ||||||||
| FaxNumber: | 6183514943 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 S 14TH STREET | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189422171 | ||||||||
| FaxNumber: | 6183514943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | WIGGS | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | ORTHOPEDIC PROGRAM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6189422171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070009719 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 336642885001 | 05 | IL | MEDICAID |