Provider Demographics
NPI:1417144726
Name:SOUTHERN ILLINOIS UROLOGY
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:HATCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-998-8884
Mailing Address - Street 1:3401 HEARTLAND ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6393
Mailing Address - Country:US
Mailing Address - Phone:618-998-8884
Mailing Address - Fax:618-998-8810
Practice Address - Street 1:3401 HEARTLAND ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-6393
Practice Address - Country:US
Practice Address - Phone:618-998-8884
Practice Address - Fax:618-998-8810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36109353174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC84396Medicare UPIN