Healthcare Provider Details

I. General information

NPI: 1306902945
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

6010 BOND AVE
EAST SAINT LOUIS IL
62207-2328
US

IV. Provider business mailing address

8080 STATE ST
EAST SAINT LOUIS IL
62203-1808
US

V. Phone/Fax

Practice location:
  • Phone: 618-337-8153
  • Fax: 618-337-8905
Mailing address:
  • Phone: 618-397-3303
  • Fax: 618-397-7802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY MCCULLEY
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 618-332-0694