Healthcare Provider Details

I. General information

NPI: 1780607291
Provider Name (Legal Business Name): SIU PHYSICIANS & SURGEONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST D235
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-7578
  • Fax: 217-545-1884
Mailing address:
  • Phone: 217-545-7578
  • Fax: 217-545-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DAVID TKACH
Title or Position: CEO
Credential:
Phone: 217-545-7578