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General NPI Number Information
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NPI Number | 1356377568
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC
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Dates
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Enumeration Date | 06/23/2006
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Last Update Date | 07/29/2009
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Provider Practice Location Address
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Address Line | 2 MEMORIAL DR SUITE 122
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City | ALTON
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State | IL
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Zip | 62002-6723
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Country | US
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Telephone | 618-465-2550
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Fax | 618-465-4167
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Provider Business Mailing Address
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Address Line | 8080 STATE ST
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62203-1808
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Country | US
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Telephone | 618-397-3303
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Fax | 618-397-7802
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. LARRY MCCULLEY
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Credential |
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Telephone | 618-332-0783
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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