Healthcare Provider Details

I. General information

NPI: 1316271653
Provider Name (Legal Business Name): PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 09/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 JEFFERSON AVE SUITE 100
MOUNT VERNON IL
62864-4309
US

IV. Provider business mailing address

413 MAIN ST
MOUNT VERNON IL
62864-3649
US

V. Phone/Fax

Practice location:
  • Phone: 618-241-1856
  • Fax: 618-241-1857
Mailing address:
  • Phone: 618-532-9350
  • Fax: 618-532-9365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RICHARD HUNTINGTON
Title or Position: VP FINANCIAL SERVICES
Credential:
Phone: 618-241-2204