Healthcare Provider Details

I. General information

NPI: 1770851875
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N 8TH ST SUITE 124
EAST SAINT LOUIS IL
62201-2989
US

IV. Provider business mailing address

8080 STATE ST
EAST SAINT LOUIS IL
62203-1808
US

V. Phone/Fax

Practice location:
  • Phone: 618-397-3303
  • Fax:
Mailing address:
  • Phone: 618-332-0953
  • Fax: 618-332-2487

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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. LARRY MCCULLEY
Title or Position: CEO
Credential:
Phone: 618-332-0783