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	License Number State
1	363LS0200X	School Nurse Practitioner
2	207Q00000X	Family Medicine Physician	IL
3	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1831254234
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	:	3939 CASEYVILLE AVE
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62204-2448
Country	:	US
Telephone Number	:	618-482-4562
Fax Number	:	618-482-4930

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

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	02/25/2013

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