Healthcare Provider Details

I. General information

NPI: 1104230168
Provider Name (Legal Business Name): BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

601 JAMES R THOMPSON BLVD BUILDING D, SUITE 2015
EAST 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 TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MYJAL GARNER
Title or Position: DIRECTOR
Credential: DNP, APRN, FNP-C
Phone: 618-482-6959