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NPI Code Detail

MEDICARE: SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.

MEDICARE: SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine Physician
2101YP2500XProfessional Counselor
31041C0700XClinical Social Worker
4122300000XDentist
5207Q00000XFamily Medicine Physician
62084P0800XPsychiatry Physician
7363A00000XPhysician Assistant
8363L00000XNurse Practitioner
9363LP0808XPsychiatric/Mental Health Nurse Practitioner
10261QF0400XFederally Qualified Health Center (FQHC)

General Provider Information

NPI Number : 1013198712
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Provider Business Mailing Address
First Line : 2041 GOOSE LAKE RD
Second Line :
City : SAUGET
State : IL
Zip : 62206-2822
Country : US
Telephone Number : 618-332-0953
Fax Number : 618-332-2487
Provider Business Practice Location Address
First Line : 900 W TEMPLE AVE STE 208
Second Line :
City : EFFINGHAM
State : IL
Zip : 62401-2187
Country : US
Telephone Number : 217-342-0211
Fax Number : 217-342-0232
Authorized Official
Title or Position : PRESIDENT/CEO
Name : MR. LARRY MCCULLEY
Credential :
Telephone Number : 618-332-0694
Provider Enumeration Date : 11/21/2007
Last Update Date : 03/01/2024

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Directions to “SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC. ” Practice Location

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