Healthcare Provider Details

I. General information

NPI: 1356377568
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEMORIAL DR SUITE 122
ALTON IL
62002-6723
US

IV. Provider business mailing address

8080 STATE ST
EAST SAINT LOUIS IL
62203-1808
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-2550
  • Fax: 618-465-4167
Mailing address:
  • Phone: 618-397-3303
  • Fax: 618-397-7802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. LARRY MCCULLEY
Title or Position: PRESIDENT
Credential:
Phone: 618-332-0783