Healthcare Provider Details

I. General information

NPI: 1578746228
Provider Name (Legal Business Name): SOUTHERN ILLINOIS MEDICAL PLAZA SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 REED STATION PKWY STE 305
CARBONDALE IL
62901-3304
US

IV. Provider business mailing address

2250 REED STATION PKWY
CARBONDALE IL
62901
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-1943
  • Fax: 618-549-2975
Mailing address:
  • Phone: 618-529-1943
  • Fax: 618-549-2975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038007699
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036093859
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN PATRICK BARRETT
Title or Position: PRESIDENT
Credential: D.C.
Phone: 618-529-1943