Provider Demographics
NPI:1467482968
Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Other - Org Name:FAMILY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-332-0783
Mailing Address - Street 1:8080 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-1808
Mailing Address - Country:US
Mailing Address - Phone:618-397-3303
Mailing Address - Fax:618-397-7802
Practice Address - Street 1:2071 GOOSE LAKE RD
Practice Address - Street 2:
Practice Address - City:SAUGET
Practice Address - State:IL
Practice Address - Zip Code:62206-2822
Practice Address - Country:US
Practice Address - Phone:618-332-5369
Practice Address - Fax:618-337-9482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL732740OtherWPS MEDICARE GROUP NUMBER
IL=========007Medicaid
IL141859Medicare ID - Type Unspecified