Healthcare Provider Details

I. General information

NPI: 1548156656
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTH CARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 JACKIE JOYNER KERSEE CIR
EAST SAINT LOUIS IL
62204-1742
US

IV. Provider business mailing address

2041 GOOSE LAKE RD
SAUGET IL
62206-2822
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-9484
  • Fax:
Mailing address:
  • Phone: 618-920-9484
  • Fax: 618-920-9484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LARRY A MCCULLEY
Title or Position: CEO
Credential:
Phone: 618-920-9484