Provider Demographics
NPI:1003035759
Name:SOUTHERN ILLINOIS OXYGEN & MED SUPPLIES
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS OXYGEN & MED SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELLA
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-285-3511
Mailing Address - Street 1:PO BOX 382
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62931-0382
Mailing Address - Country:US
Mailing Address - Phone:618-285-3511
Mailing Address - Fax:618-285-3597
Practice Address - Street 1:1107 W 10TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2432
Practice Address - Country:US
Practice Address - Phone:618-524-2825
Practice Address - Fax:618-524-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0230910002Medicare NSC