Healthcare Provider Details

I. General information

NPI: 1871882787
Provider Name (Legal Business Name): SIU PHYSICIANS & SURGEONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 07/21/2022
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W CARPENTER ST
SPRINGFIELD IL
62702-4901
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-5817
  • Fax: 217-545-1141
Mailing address:
  • Phone: 217-545-7578
  • Fax: 217-545-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: JERRY KRUSE
Title or Position: CEO
Credential:
Phone: 217-545-7876