MEDICARE: SOUTHERN ILLINOIS REGIONAL WELLNESS CENTER

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
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1265588776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN ILLINOIS REGIONAL WELLNESS CENTER

Provider Business Mailing Address
First Line	:	1835 KINGSHIGHWAY
Second Line	:
City	:	WASHINGTON PARK
State	:	IL
Zip	:	62204-2135
Country	:	US
Telephone Number	:	618-482-7922
Fax Number	:	618-482-7881

Provider Business Practice Location Address
First Line	:	1835 KINGSHIGHWAY
Second Line	:
City	:	WASHINGTON PARK
State	:	IL
Zip	:	62204-2135
Country	:	US
Telephone Number	:	618-482-7922
Fax Number	:	618-482-7881

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MARK R FREELAND
Credential	:
Telephone Number	:	618-874-3120

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	12/06/2011

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