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General NPI Number Information
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NPI Number | 1023001377
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS ORTHOPEDIC CENTER,LLC
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Dates
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Enumeration Date | 08/23/2005
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Last Update Date | 05/28/2024
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Provider Practice Location Address
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Address Line | 510 LINCOLN DR
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City | HERRIN
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State | IL
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Zip | 62948-6334
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Country | US
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Telephone | 618-997-3100
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Fax | 618-997-3616
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Provider Business Mailing Address
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Address Line | 600 S CLIFF AVE STE 106
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City | SIOUX FALLS
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State | SD
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Zip | 57104-5355
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Country | US
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Telephone | 618-997-3100
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Fax | 618-997-3616
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | JUSTIN HARRIS
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Credential | MSHA, MBA, FACHE
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Telephone | 859-537-7001
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 7002421
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License Number State | IL
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