Healthcare Provider Details

I. General information

NPI: 1508924093
Provider Name (Legal Business Name): SIU PHYSICIANS & SURGEONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W JACKSON ST SUITE 200
CARBONDALE IL
62901-1474
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-3777
  • Fax: 618-453-1102
Mailing address:
  • Phone: 217-545-7578
  • Fax: 217-545-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. NELSON C WEICHOLD
Title or Position: CFO
Credential:
Phone: 217-545-7578