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	101Y00000X	Counselor
2	1041C0700X	Clinical Social Worker
3	207Q00000X	Family Medicine Physician
4	363LF0000X	Family Nurse Practitioner
5	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
6	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1740345156
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	:	1736 KINGSHIGHWAY
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204
Country	:	US
Telephone Number	:	618-874-3120
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MR. LARRY MCCULLEY
Credential	:
Telephone Number	:	618-332-0694

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	06/27/2019

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