Healthcare Provider Details

I. General information

NPI: 1720199748
Provider Name (Legal Business Name): SOUTHERN ILLINOIS SURGICAL APPLIANCE CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W MAIN ST
CARBONDALE IL
62901-2227
US

IV. Provider business mailing address

PO BOX 1667
MOUNT VERNON IL
62864-0033
US

V. Phone/Fax

Practice location:
  • Phone: 618-529-2406
  • Fax: 618-351-7466
Mailing address:
  • Phone: 618-529-2406
  • Fax: 618-351-7466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number2032-1120
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number2032-1120
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number2032-1120
License Number StateIL

VIII. Authorized Official

Name: MR. RALPH RANDOLPH LEWIS
Title or Position: PRESIDENT
Credential:
Phone: 618-932-3157