Basic Information
| Provider Information | |||||||||
| NPI: | 1538689062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ILLINOIS MEDICAL SERVICES, NFP | ||||||||
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| OtherOrganizationName: | SIH MEDICAL GROUP ANNA PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1239 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | 6183514820 | ||||||||
| Practice Location | |||||||||
| Address1: | 98 PEACH RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ANNA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629062243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186141400 | ||||||||
| FaxNumber: | 6186141401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LINGLE | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6184575200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN ILLINOIS HOSPITAL SERVICES | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 1770656837 | 05 | IL | MEDICAID |