Provider Demographics
NPI:1144405291
Name:SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS/CORP SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-842-4470
Mailing Address - Street 1:209 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1218
Mailing Address - Country:US
Mailing Address - Phone:618-842-4470
Mailing Address - Fax:618-842-3437
Practice Address - Street 1:209 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1218
Practice Address - Country:US
Practice Address - Phone:618-842-4470
Practice Address - Fax:618-842-3437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207R00000X, 207V00000X, 208000000X, 363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid
IL975940Medicare PIN