Healthcare Provider Details

I. General information

NPI: 1982738274
Provider Name (Legal Business Name): INTEGRATED HEALTH OF SOUTHERN ILLINOIS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S COMMERCIAL ST STE 10
HARRISBURG IL
62946-2125
US

IV. Provider business mailing address

303 S COMMERCIAL ST STE 10
HARRISBURG IL
62946-2125
US

V. Phone/Fax

Practice location:
  • Phone: 618-252-5555
  • Fax: 618-252-2279
Mailing address:
  • Phone: 618-252-5555
  • Fax: 618-252-2279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number042-619186
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number042619186
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number042620395
License Number StateIL

VIII. Authorized Official

Name: DR. BRIAN HESTER
Title or Position: OWNER
Credential: DC
Phone: 618-252-5555