Healthcare Provider Details

I. General information

NPI: 1750104162
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CHAFFER AVE
ROXANA IL
62084-1125
US

IV. Provider business mailing address

2041 GOOSE LAKE RD
SAUGET IL
62206-2822
US

V. Phone/Fax

Practice location:
  • Phone: 332-332-0953
  • Fax:
Mailing address:
  • Phone: 618-332-0953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JAMES F SPINNER
Title or Position: SR. DIRECTOR OF COMPLIANCE
Credential:
Phone: 618-332-0953