Healthcare Provider Details

I. General information

NPI: 1396097960
Provider Name (Legal Business Name): BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 4TH ST
SPRINGFIELD IL
62702-5238
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-8100
  • Fax: 217-747-1351
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-4410

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 Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: IRIS WESLEY
Title or Position: CEO
Credential:
Phone: 217-545-8000