Provider Demographics
NPI:1326041708
Name:SOUTHWESTERN ILLINOIS COLLEGE PROGRAMS FOR OLDER PSREONS
Entity Type:Organization
Organization Name:SOUTHWESTERN ILLINOIS COLLEGE PROGRAMS FOR OLDER PSREONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-234-4410
Mailing Address - Street 1:201 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-4005
Mailing Address - Country:US
Mailing Address - Phone:618-234-4410
Mailing Address - Fax:618-234-8634
Practice Address - Street 1:201 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-4005
Practice Address - Country:US
Practice Address - Phone:618-234-4410
Practice Address - Fax:618-234-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL343580Medicare ID - Type UnspecifiedWISCONSIN PHYSICIANS SERV