Healthcare Provider Details

I. General information

NPI: 1508953746
Provider Name (Legal Business Name): SOUTHERN ILLINOIS PHYSICIAN SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MEMORIAL DRIVE SUITE 340
BELLEVILLE IL
62226
US

IV. Provider business mailing address

P.O. BOX 23620
BELLEVILLE IL
62223-0620
US

V. Phone/Fax

Practice location:
  • Phone: 618-222-9999
  • Fax: 618-222-9337
Mailing address:
  • Phone: 618-222-9999
  • Fax: 618-222-9337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA J TIBEREND
Title or Position: BILLING OFFICER SUPERVISOR
Credential:
Phone: 618-222-9999