Healthcare Provider Details

I. General information

NPI: 1427749845
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT ANTHONYS WAY STE 101
ALTON IL
62002-4580
US

IV. Provider business mailing address

2041 GOOSE LAKE RD
SAUGET IL
62206-2822
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-0953
  • Fax:
Mailing address:
  • Phone: 618-332-0953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY MCCULLEY
Title or Position: PRESIDENT/CEO
Credential:
Phone: 618-332-0694