Basic Information
| Provider Information | |||||||||
| NPI: | 1952042814 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2041 GOOSE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SAUGET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622062822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183320953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 E FAIRCHILD ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618323114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183320953 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2022 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | SPINNER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR HEALTH CTR. COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 6183320953 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.