Basic Information
| Provider Information | |||||||||
| NPI: | 1770656837 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ILLINOIS MEDICAL SERVICES NFP | ||||||||
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| OtherOrganizationName: | SIH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1239 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | 6185290568 | ||||||||
| Practice Location | |||||||||
| Address1: | 1239 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184575200 | ||||||||
| FaxNumber: | 6185495128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 05/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | SCHAEFER | ||||||||
| AuthorizedOfficialFirstName: | PHIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VP | ||||||||
| AuthorizedOfficialTelephone: | 6184575200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3932056 | 01 | IL | BCBS | OTHER |