Healthcare Provider Details

I. General information

NPI: 1376630103
Provider Name (Legal Business Name): SOUTHERN ILLINOIS INTERNAL MEDICINE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DRIVE SUITE 310
BELLEVILLE IL
62226-5366
US

IV. Provider business mailing address

4600 MEMORIAL DRIVE SUITE 310
BELLEVILLE IL
62226-5366
US

V. Phone/Fax

Practice location:
  • Phone: 618-235-8720
  • Fax: 618-235-8725
Mailing address:
  • Phone: 618-235-8720
  • Fax: 618-235-8725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MAZHAR H LAKHO
Title or Position: OWNER PHYSICIAN
Credential: MD
Phone: 618-235-8720