Healthcare Provider Details

I. General information

NPI: 1215978127
Provider Name (Legal Business Name): BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W OAK ST STE 100
CARBONDALE IL
62901-1496
US

IV. Provider business mailing address

201 E MADISON ST STE 328
SPRINGFIELD IL
62702-5131
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-3777
  • Fax: 618-453-1102
Mailing address:
  • Phone: 217-545-6523
  • Fax: 217-545-4410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. IRIS WESLEY
Title or Position: C.E.O.
Credential:
Phone: 217-545-8137