Healthcare Provider Details

I. General information

NPI: 1609358647
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTH CARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 GOOSE LAKE RD
SAUGET IL
62206-2822
US

IV. Provider business mailing address

2041 GOOSE LAKE RD
SAUGET IL
62206-2822
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

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