Healthcare Provider Details

I. General information

NPI: 1245396886
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 STATE ST
EAST SAINT LOUIS IL
62205-1803
US

IV. Provider business mailing address

8080 STATE ST
EAST SAINT LOUIS IL
62203-1808
US

V. Phone/Fax

Practice location:
  • Phone: 618-271-0207
  • Fax: 618-271-9617
Mailing address:
  • Phone: 618-397-3303
  • Fax: 618-397-7802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. LARRY MCCULLEY
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 618-332-0783