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General NPI Number Information
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NPI Number | 1780688671
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Entity Type | Organization
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Legal Business Name | PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC
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Dates
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Enumeration Date | 06/08/2005
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Last Update Date | 08/26/2015
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Provider Practice Location Address
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Address Line | 1441 W BROADWAY
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City | CENTRALIA
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State | IL
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Zip | 62801-0001
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Country | US
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Telephone | 618-532-9050
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Fax |
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Provider Business Mailing Address
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Address Line | 1411 W BROADWAY
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City | CENTRALIA
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State | IL
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Zip | 62801-0001
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Country | US
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Telephone | 618-532-9050
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Fax | 618-532-9365
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Authorized Official
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Title or Position | VP FINANCE MEDICAL GROUP
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Name | MR. DEE EVISCHI
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Credential |
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Telephone | 618-899-1040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 0002642
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License Number State | IL
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