Provider Demographics
NPI:1023001377
Name:SOUTHERN ILLINOIS ORTHOPEDIC CENTER,LLC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS ORTHOPEDIC CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-997-3100
Mailing Address - Street 1:600 S CLIFF AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-5355
Mailing Address - Country:US
Mailing Address - Phone:618-997-3100
Mailing Address - Fax:618-997-3616
Practice Address - Street 1:510 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-997-3100
Practice Address - Fax:618-997-3616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL7002421261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
066440OtherHEALTH ALLIANCE
133621000OtherUS DEPT OF LABOR
IL1458OtherBC/BS
441874OtherHEALTHLINK
=========OtherTRICARE
IL=========001Medicaid
IL1458OtherBC/BS
066440OtherHEALTH ALLIANCE
=========OtherCHAMPVA
IL632890Medicare PIN