Basic Information
| Provider Information | |||||||||
| NPI: | 1558385989 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIU PHYSICIANS & SURGEONS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20907 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627080907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175454410 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E MADISON ST STE 328 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175456523 | ||||||||
| FaxNumber: | 2175454410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BURDICK | ||||||||
| AuthorizedOfficialFirstName: | SHELBY | ||||||||
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| AuthorizedOfficialTitleorPosition: | TEAM LEAD, MEDICAL STAFF SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2175456523 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207Q00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 2084P0800X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208M00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207RE0101X | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | CE8689 | 01 | IL | RR MEDICARE | OTHER | CE8688 | 01 | IL | RR MEDICARE | OTHER | CB2589 | 01 | IL | RR MEDICARE | OTHER | CE8686 | 01 | IL | RR MEDICARE | OTHER | CE8687 | 01 | IL | RR MEDICARE | OTHER | CE8931 | 01 | IL | RR MEDICARE | OTHER |