Basic Information
| Provider Information | |||||||||
| NPI: | 1609358647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN ILLINOIS HEALTH CARE FOUNDATION, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SIHF HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2041 GOOSE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SAUGET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622062822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183320953 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2041 GOOSE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SAUGET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622062822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183320953 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2018 | ||||||||
| LastUpdateDate: | 12/07/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCULLEY | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6183320694 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 251B00000X | Y | Agencies | Case Management |
No ID Information.