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General NPI Number Information
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NPI Number | 1215978127
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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 | 06/10/2006
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Last Update Date | 05/03/2022
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Provider Practice Location Address
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Address Line | 300 W OAK ST STE 100
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City | CARBONDALE
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State | IL
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Zip | 62901-1496
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Country | US
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Telephone | 618-453-3777
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Fax | 618-453-1102
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Provider Business Mailing Address
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Address Line | 201 E MADISON ST STE 328
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City | SPRINGFIELD
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State | IL
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Zip | 62702-5131
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Country | US
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Telephone | 217-545-6523
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Fax | 217-545-4410
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Authorized Official
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Title or Position | C.E.O.
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Name | MR. IRIS WESLEY
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Credential |
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Telephone | 217-545-8137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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