Provider Demographics
NPI:1215204938
Name:SOUTHERN ILLINOIS MEDICAL SERVICES, NFP
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS MEDICAL SERVICES, NFP
Other - Org Name:LOGAN PRIMARY CARE SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REX
Authorized Official - Middle Name:P
Authorized Official - Last Name:BUDDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-5200
Mailing Address - Street 1:405 RUSHING DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3730
Mailing Address - Country:US
Mailing Address - Phone:618-993-3300
Mailing Address - Fax:618-997-6626
Practice Address - Street 1:502 W ST LOUIS
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-1968
Practice Address - Country:US
Practice Address - Phone:618-997-3400
Practice Address - Fax:618-932-3797
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS HOSPITAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL148969Medicare Oscar/Certification