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General NPI Number Information
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NPI Number | 1629086806
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS FAMILY MEDICINE CORPORATION
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 02/01/2018
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Provider Practice Location Address
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Address Line | 104 MAGNOLIA DR STE A
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City | GLEN CARBON
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State | IL
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Zip | 62034-1595
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Country | US
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Telephone | 618-288-9466
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Fax |
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Provider Business Mailing Address
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Address Line | 104 MAGNOLIA DR STE A
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City | GLEN CARBON
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State | IL
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Zip | 62034-1595
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Country | US
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Telephone | 618-288-9466
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JIM HONG
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Credential | MD
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Telephone | 618-288-9466
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036114185
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License Number State | IL
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