Basic Information
| Provider Information | |||||||||
| NPI: | 1700278371 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SIU HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172249484 | ||||||||
| FaxNumber: | 2172247894 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172249484 | ||||||||
| FaxNumber: | 2172247894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2015 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | HATTEY | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2172249484 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.