Healthcare Provider Details

I. General information

NPI: 1285749184
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTH CARE ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 VANDALIA ST SECOND FLOOR
COLLINSVILLE IL
62234-4061
US

IV. Provider business mailing address

531 VANDALIA ST SECOND FLOOR
COLLINSVILLE IL
62234-4061
US

V. Phone/Fax

Practice location:
  • Phone: 618-345-3160
  • Fax: 618-345-3616
Mailing address:
  • Phone: 618-345-3160
  • Fax: 618-345-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER M. DEMICK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-345-3160