=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245442375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN ILLINOIS HAND CENTER, SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 04/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 MEDICAL PARK DRIVE SUITE 100
-----------------------------------------------------
City | EFFINGHAM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-347-3003
-----------------------------------------------------
Fax | 217-347-3005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 MEDICAL PARK DRIVE SUITE 100
-----------------------------------------------------
City | EFFINGHAM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-347-3003
-----------------------------------------------------
Fax | 217-347-3005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NASH NAAM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 217-347-3003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0105X
-----------------------------------------------------
Taxonomy Name | Surgery of the Hand (Surgery) Physician
-----------------------------------------------------
License Number | 36067047
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------