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
1	207Q00000X	Family Medicine Physician
2	207R00000X	Internal Medicine Physician
3	207RC0000X	Cardiovascular Disease Physician
4	207Y00000X	Otolaryngology Physician
5	363A00000X	Physician Assistant
6	363L00000X	Nurse Practitioner
7	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1306902945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.

Provider Business Mailing Address
First Line	:	8080 STATE ST
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62203-1808
Country	:	US
Telephone Number	:	618-397-3303
Fax Number	:	618-397-7802

Provider Business Practice Location Address
First Line	:	6010 BOND AVE
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62207-2328
Country	:	US
Telephone Number	:	618-337-8153
Fax Number	:	618-337-8905

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. LARRY MCCULLEY
Credential	:
Telephone Number	:	618-332-0694

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	10/30/2008

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