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General NPI Number Information
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NPI Number | 1104230168
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Entity Type | Organization
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Legal Business Name | BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
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Dates
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Enumeration Date | 06/18/2014
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Last Update Date | 01/08/2025
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Provider Practice Location Address
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Address Line | 601 JAMES R THOMPSON BLVD BUILDING D, SUITE 2015
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62201-1129
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Country | US
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Telephone | 618-482-6959
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Fax | 618-482-8311
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Provider Business Mailing Address
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Address Line | 601 JAMES R THOMPSON BLVD BUILDING D, SUITE 2015
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62201-1129
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Country | US
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Telephone | 618-482-6959
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Fax | 618-482-8311
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. MYJAL GARNER
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Credential | DNP, APRN, FNP-C
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Telephone | 618-482-6959
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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