Healthcare Provider Details

I. General information

NPI: 1306273776
Provider Name (Legal Business Name): SOUTHERN ILLINOIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JAMES R THOMPSON BLVD BUILDING D, SUITE 2015
E SAINT LOUIS IL
62201-1129
US

IV. Provider business mailing address

601 JAMES R THOMPSON BLVD BUILDING D, SUITE 2015
E SAINT LOUIS IL
62201-1129
US

V. Phone/Fax

Practice location:
  • Phone: 618-482-6959
  • Fax: 618-482-8311
Mailing address:
  • Phone: 618-482-6959
  • Fax: 618-482-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIM WENONA WHITE
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD, PHCNS-BC
Phone: 618-482-6959