MEDICARE: SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	207Q00000X	Family Medicine Physician	IL
2	207R00000X	Internal Medicine Physician	IL
3	207RC0000X	Cardiovascular Disease Physician	IL
4	207RN0300X	Nephrology Physician	IL
5	261QF0400X	Federally Qualified Health Center (FQHC)	IL

General Provider Information

NPI Number	:	1083162432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.

Provider Business Mailing Address
First Line	:	2041 GOOSE LAKE RD
Second Line	:
City	:	SAUGET
State	:	IL
Zip	:	62206-2822
Country	:	US
Telephone Number	:	618-332-0953
Fax Number	:

Provider Business Practice Location Address
First Line	:	2071 GOOSE LAKE RD
Second Line	:
City	:	SAUGET
State	:	IL
Zip	:	62206-2822
Country	:	US
Telephone Number	:	618-337-9461
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. LARRY MCCULLEY
Credential	:
Telephone Number	:	618-332-0694

Provider Enumeration Date	:	09/14/2016
Last Update Date	:	03/01/2024

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