Healthcare Provider Details

I. General information

NPI: 1932192622
Provider Name (Legal Business Name): SOUTHWEST ILLINOIS HEALTH SERVICES, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 NORTH ILLINOIS SUITE A
SWANSEA IL
62226-1496
US

IV. Provider business mailing address

4000 NORTH ILLINOIS SUITE A
SWANSEA IL
62226-1496
US

V. Phone/Fax

Practice location:
  • Phone: 618-236-9770
  • Fax: 618-236-9780
Mailing address:
  • Phone: 618-236-9770
  • Fax: 618-236-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberIL-01836-01
License Number StateIL

VIII. Authorized Official

Name: JANE GUSMANO
Title or Position: VICE PRESIDENT
Credential:
Phone: 618-257-5607