Provider Demographics
NPI:1023034618
Name:HEALTHCARE PHYSICIANS OF SOUTHERN ILLINOIS, PC
Entity Type:Organization
Organization Name:HEALTHCARE PHYSICIANS OF SOUTHERN ILLINOIS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:V
Authorized Official - Last Name:VEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-222-9999
Mailing Address - Street 1:PO BOX 24007
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-9007
Mailing Address - Country:US
Mailing Address - Phone:618-222-9999
Mailing Address - Fax:618-222-9337
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5366
Practice Address - Country:US
Practice Address - Phone:618-222-9999
Practice Address - Fax:618-222-9337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095025207Q00000X
IL036096642207Q00000X
IL036096627207Q00000X
IL036087648207R00000X
IL036092347207R00000X
IL036093757207R00000X
IL036108140207R00000X
IL036106952207R00000X
IL036113541207R00000X
IL036087011207R00000X
IL036114966207R00000X
IL036053136207RP1001X
IL036091795207RP1001X
IL036114207207RP1001X
IL036114259207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08221043OtherBCBS OF ILLINOIS ID#
IL208438Medicare ID - Type Unspecified
IL08221043OtherBCBS OF ILLINOIS ID#