Healthcare Provider Details

I. General information

NPI: 1053804443
Provider Name (Legal Business Name): SIU PHYSICIANS & SURGEONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N WESTGATE AVE
JACKSONVILLE IL
62650-1152
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-243-8455
  • Fax:
Mailing address:
  • Phone: 217-545-7876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JO TURLEY
Title or Position: MEDICAL STAFF COORDINATOR
Credential:
Phone: 217-545-7876