Provider Demographics
NPI:1306022322
Name:SOUTHERN ILLINOIS SURGICAL APPLIANCE COMPANY
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS SURGICAL APPLIANCE COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-642-0501
Mailing Address - Street 1:8305 EXPRESS DR. -C
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6359
Mailing Address - Country:US
Mailing Address - Phone:618-969-8010
Mailing Address - Fax:
Practice Address - Street 1:8305 EXPRESS DR. C
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-6359
Practice Address - Country:US
Practice Address - Phone:618-969-8010
Practice Address - Fax:618-969-8014
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS APPLIANCE COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========008Medicaid
IL0251010007Medicare NSC