MEDICARE: BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY

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)		IL

General Provider Information

NPI Number	:	1649628009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY

Provider Business Mailing Address
First Line	:	520 N 4TH ST
Second Line	:	PO BOX 19671
City	:	SPRINGFIELD
State	:	IL
Zip	:	62702-5238
Country	:	US
Telephone Number	:	217-545-8000
Fax Number	:	217-747-1351

Provider Business Practice Location Address
First Line	:	345 W STATE ST
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-1879
Country	:	US
Telephone Number	:	217-245-5111
Fax Number	:	217-243-4773

Authorized Official
Title or Position	:	CEO
Name	:	IRIS WESLEY
Credential	:
Telephone Number	:	217-545-8000

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	05/26/2016

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