=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285657379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIU PHYSICIANS & SURGEONS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 N 1ST ST D235
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62781-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-545-7578
-----------------------------------------------------
Fax | 217-545-1884
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 19639
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62794-9639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-545-7578
-----------------------------------------------------
Fax | 217-545-1884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DAVID TKACH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-545-7578
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207SG0201X
-----------------------------------------------------
Taxonomy Name | Clinical Genetics (M.D.) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0006X
-----------------------------------------------------
Taxonomy Name | Developmental - Behavioral Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2080P0206X
-----------------------------------------------------
Taxonomy Name | Pediatric Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2080P0208X
-----------------------------------------------------
Taxonomy Name | Pediatric Infectious Diseases Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2080P0210X
-----------------------------------------------------
Taxonomy Name | Pediatric Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------