Healthcare Provider Details

I. General information

NPI: 1831337450
Provider Name (Legal Business Name): PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 LINCOLNSHIRE DR
MOUNT VERNON IL
62864-2156
US

IV. Provider business mailing address

4218 LINCOLNSHIRE DR PO BOX 968
MOUNT VERNON IL
62864-2156
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-9350
  • Fax:
Mailing address:
  • Phone: 618-532-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036113387
License Number StateIL

VIII. Authorized Official

Name: TAMMY L SIMONTON
Title or Position: BILLING MNG
Credential:
Phone: 618-436-6267