Provider Demographics
NPI:1437163367
Name:SOUTHERN ILLINOIS RHEUMATOLOGY, SC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS RHEUMATOLOGY, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:PFALZGRAF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:618-529-2200
Mailing Address - Street 1:PO BOX 2963
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-2963
Mailing Address - Country:US
Mailing Address - Phone:618-529-2200
Mailing Address - Fax:
Practice Address - Street 1:317 S 14TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3601
Practice Address - Country:US
Practice Address - Phone:618-529-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH18358Medicare UPIN