=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245538859
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN ILLINOIS SURGICAL CARE ASSOCIATES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2011
-----------------------------------------------------
Last Update Date | 03/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 NW 10TH ST
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62837-1237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-842-3813
-----------------------------------------------------
Fax | 618-842-2514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 NW 10TH ST P.O. BOX 465
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62837-1237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-842-3813
-----------------------------------------------------
Fax | 618-842-2514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PATRICK L MOLT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 618-842-3813
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 036-100303
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------