Provider Demographics
NPI:1508953746
Name:SOUTHERN ILLINOIS PHYSICIAN SERVICES, PC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS PHYSICIAN SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICER SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J
Authorized Official - Last Name:TIBEREND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-222-9999
Mailing Address - Street 1:P.O. BOX 23620
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-0620
Mailing Address - Country:US
Mailing Address - Phone:618-222-9999
Mailing Address - Fax:618-222-9337
Practice Address - Street 1:4600 MEMORIAL DRIVE
Practice Address - Street 2:SUITE 340
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-222-9999
Practice Address - Fax:618-222-9337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherGROUP FEIN #