Healthcare Provider Details

I. General information

NPI: 1396386181
Provider Name (Legal Business Name): BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 10/02/2019
Certification Date:
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

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 618-536-6621
  • Fax:
Mailing address:
  • Phone: 217-545-7876
  • Fax:

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: IRIS WESLEY
Title or Position: CEO
Credential:
Phone: 217-545-8000