Basic Information
| Provider Information | |||||||||
| NPI: | 1558539882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DEPARTMENT OF PSYCHIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19642 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458229 | ||||||||
| FaxNumber: | 2175452275 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 W JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627024833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458229 | ||||||||
| FaxNumber: | 2175452275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2008 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | TKACH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2175457578 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 10-0066401 | IL | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 100066401002 | 05 | IL | MEDICAID |