Provider Demographics
NPI:1215208798
Name:SOUTHERN ILLINOIS HISTOLOGY, LLC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS HISTOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOLPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAEGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-798-3000
Mailing Address - Street 1:PO BOX 144333
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-4333
Mailing Address - Country:US
Mailing Address - Phone:407-422-9831
Mailing Address - Fax:407-206-1767
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4701
Practice Address - Country:US
Practice Address - Phone:618-798-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty