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General NPI Number Information
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NPI Number | 1861909509
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Entity Type | Organization
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Legal Business Name | SOUTHERN ILLINOIS NEUROPSYCHOLOGY LLC
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Dates
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Enumeration Date | 01/03/2018
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Last Update Date | 02/10/2022
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Provider Practice Location Address
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Address Line | 60 S STATE ROUTE 157
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City | EDWARDSVILLE
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State | IL
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Zip | 62025
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Country | US
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Telephone | 618-391-4021
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Fax |
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Provider Business Mailing Address
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Address Line | 1 OAK DR UNIT 352
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City | MARYVILLE
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State | IL
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Zip | 62062-7026
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Country | US
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Telephone | 618-391-4021
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. PHILLIP RUPPERT
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Credential | PHD
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Telephone | 618-391-4021
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 071009269
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License Number State | IL
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