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General NPI Number Information
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NPI Number | 1508301706
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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 | 12/23/2016
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Last Update Date | 12/23/2022
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Provider Practice Location Address
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Address Line | 1710 STATE ROUTE 133
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City | ARTHUR
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State | IL
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Zip | 61911
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Country | US
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Telephone | 217-543-2446
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Fax | 217-543-2548
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Provider Business Mailing Address
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Address Line | 2041 GOOSE LAKE RD
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City | SAUGET
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State | IL
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Zip | 62206-2822
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Country | US
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Telephone | 618-332-0694
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Fax | 618-332-2487
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Authorized Official
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Title or Position | CEO
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Name | MR. LARRY MCCULLEY
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Credential |
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Telephone | 618-973-6229
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State | IL
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Taxonomy #5
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State | IL
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Taxonomy #6
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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 | IL
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