Provider Demographics
NPI:1376630103
Name:SOUTHERN ILLINOIS INTERNAL MEDICINE LTD
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS INTERNAL MEDICINE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MAZHAR
Authorized Official - Middle Name:H
Authorized Official - Last Name:LAKHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-235-8720
Mailing Address - Street 1:4600 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5366
Mailing Address - Country:US
Mailing Address - Phone:618-235-8720
Mailing Address - Fax:618-235-8725
Practice Address - Street 1:4600 MEMORIAL DRIVE
Practice Address - Street 2:SUITE 310
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5366
Practice Address - Country:US
Practice Address - Phone:618-235-8720
Practice Address - Fax:618-235-8725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E37069Medicare UPIN
IL205770Medicare ID - Type Unspecified