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NPI Code Detail

MEDICARE: SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C.

MEDICARE: SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C.
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine PhysicianIL
2207V00000XObstetrics & Gynecology PhysicianIL
3208000000XPediatrics PhysicianIL
4363A00000XPhysician AssistantIL
5363L00000XNurse PractitionerIL
6207Q00000XFamily Medicine PhysicianIL

General Provider Information

NPI Number : 1144405291
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C.
Provider Business Mailing Address
First Line : 209 NW 11TH ST
Second Line :
City : FAIRFIELD
State : IL
Zip : 62837-1218
Country : US
Telephone Number : 618-842-4470
Fax Number : 618-842-3437
Provider Business Practice Location Address
First Line : 209 NW 11TH ST
Second Line :
City : FAIRFIELD
State : IL
Zip : 62837-1218
Country : US
Telephone Number : 618-842-4470
Fax Number : 618-842-3437
Authorized Official
Title or Position : DIRECTOR OF BUSINESS/CORP SECRETARY
Name : CATHY L HARTE
Credential :
Telephone Number : 618-842-4470
Provider Enumeration Date : 01/08/2008
Last Update Date : 04/20/2008

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