Healthcare Provider Details

I. General information

NPI: 1649628009
Provider Name (Legal Business Name): BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 W STATE ST
JACKSONVILLE IL
62650-1879
US

IV. Provider business mailing address

520 N 4TH ST PO BOX 19671
SPRINGFIELD IL
62702-5238
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-5111
  • Fax: 217-243-4773
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-747-1351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateIL

VIII. Authorized Official

Name: IRIS WESLEY
Title or Position: CEO
Credential:
Phone: 217-545-8000