Basic Information
| Provider Information | |||||||||
| NPI: | 1912904574 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 NW 11TH ST | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628371218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188424470 | ||||||||
| FaxNumber: | 6188423437 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 NW 11TH ST | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628371218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188424470 | ||||||||
| FaxNumber: | 6188423437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 01/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | HARTE | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS/CORP SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6188424470 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 060005614 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | 060005614 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | 060005614 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363L00000X | 060005614 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | 060005614 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | 060005614 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.