Healthcare Provider Details

I. General information

NPI: 1083162432
Provider Name (Legal Business Name): SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2071 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: 618-337-9461
  • 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 StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateIL

VIII. Authorized Official

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