Healthcare Provider Details

I. General information

NPI: 1447441308
Provider Name (Legal Business Name): SOUTHERN ILLINOIS OXYGEN, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 146
ROSICLARE IL
62982
US

IV. Provider business mailing address

PO BOX 382
ELIZABETHTOWN IL
62931-0382
US

V. Phone/Fax

Practice location:
  • Phone: 618-285-3511
  • Fax: 618-285-3597
Mailing address:
  • Phone: 618-285-3511
  • Fax: 618-285-3597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier332B00000X
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerPROVIDER TAXONOMY NUMBER

VIII. Authorized Official

Name: MRS. DELLA DARLENE PUGH
Title or Position: PRESIDENT
Credential: R.N.
Phone: 618-285-6370