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General NPI Number Information
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NPI Number | 1508953746
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS PHYSICIAN SERVICES, PC
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Dates
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Enumeration Date | 10/09/2006
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 4600 MEMORIAL DRIVE SUITE 340
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City | BELLEVILLE
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State | IL
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Zip | 62226
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Country | US
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Telephone | 618-222-9999
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Fax | 618-222-9337
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Provider Business Mailing Address
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Address Line | P.O. BOX 23620
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City | BELLEVILLE
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State | IL
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Zip | 62223-0620
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Country | US
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Telephone | 618-222-9999
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Fax | 618-222-9337
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Authorized Official
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Title or Position | BILLING OFFICER SUPERVISOR
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Name | REBECCA J TIBEREND
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Credential |
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Telephone | 618-222-9999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | 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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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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 | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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