Provider Demographics
NPI:1376921924
Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Other - Org Name:SIU QUINCY FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-757-8000
Mailing Address - Street 1:612 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2662
Mailing Address - Country:US
Mailing Address - Phone:217-224-9484
Mailing Address - Fax:217-224-7950
Practice Address - Street 1:612 N 11TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2662
Practice Address - Country:US
Practice Address - Phone:217-224-9484
Practice Address - Fax:217-224-7950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-15
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)