Healthcare Provider Details

I. General information

NPI: 1740421536
Provider Name (Legal Business Name): PHYSICIAN SERVICES CORP OF SOUTHERN ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N PLEASANT AVE
CENTRALIA IL
62801-3006
US

IV. Provider business mailing address

430 N PLEASANT AVE
CENTRALIA IL
62801-3006
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-9350
  • Fax:
Mailing address:
  • Phone: 618-532-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number002642
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036116791
License Number StateIL

VIII. Authorized Official

Name: TAMMY SIMONTON
Title or Position: MNG
Credential:
Phone: 618-436-6267