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	261QP2300X	Primary Care Clinic/Center
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1770259764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY

Provider Business Mailing Address
First Line	:	PO BOX 19639
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62794-9639
Country	:	US
Telephone Number	:	217-545-6523
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 E CLEAR LAKE AVE STE 120
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-1172
Country	:	US
Telephone Number	:	217-545-8000
Fax Number	:

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

Provider Enumeration Date	:	08/19/2021
Last Update Date	:	01/09/2025

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