Provider Demographics
NPI:1467476895
Name:SIU PHYSICIANS & SURGEONS, INC
Entity Type:Organization
Organization Name:SIU PHYSICIANS & SURGEONS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TKACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-545-7578
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-7578
Mailing Address - Fax:217-545-1884
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:D235
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-545-7578
Practice Address - Fax:217-545-1884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YA0400X, 101YP2500X, 103G00000X, 103T00000X, 103TC0700X, 1041C0700X, 2084N0400X, 2084N0402X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCE8689OtherRR MEDICARE
ILCE8931OtherRR MEDICARE
ILCB2589OtherRR MEDICARE
ILCE8686OtherRR MEDICARE
ILCE8688OtherRR MEDICARE
ILCE8687OtherRR MEDICARE
ILCE8687OtherRR MEDICARE
ILCE8689OtherRR MEDICARE
IL256514Medicare PIN