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	License Number State
1	261Q00000X	Clinic/Center
2	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1174688501
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	:	618-332-2487

Provider Business Practice Location 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	:	618-332-2487

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

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	04/24/2025

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