Provider Demographics
NPI:1508924093
Name:SIU PHYSICIANS & SURGEONS, INC.
Entity Type:Organization
Organization Name:SIU PHYSICIANS & SURGEONS, INC.
Other - Org Name:SOUTHERN ILLINOIS FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:C
Authorized Official - Last Name:WEICHOLD
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 1:305 W JACKSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-453-3777
Practice Address - Fax:618-453-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL148995Medicare PIN