Healthcare Provider Details

I. General information

NPI: 1225556996
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 4000
O FALLON IL
62269-1099
US

IV. Provider business mailing address

2041 GOOSE LAKE RD
SAUGET IL
62206-2822
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-5480
  • Fax:
Mailing address:
  • Phone: 16183320953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateIL

VIII. Authorized Official

Name: LARRY MCCULLEY
Title or Position: CEO
Credential:
Phone: 618-332-0694