Provider Demographics
NPI:1083121537
Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Other - Org Name:SIU CENTER FOR FAMILY MEDICINE - ADAMS COUNTY DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-545-8000
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-7876
Mailing Address - Fax:
Practice Address - Street 1:330 VERMONT ST STE 100
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2700
Practice Address - Country:US
Practice Address - Phone:217-222-8440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)