Provider Demographics
NPI:1518343722
Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Other - Org Name:SIU CENTER FOR FAMILY MEDICINE - NOLL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/FQHC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-545-8000
Mailing Address - Street 1:PO BOX 19670
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9670
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-747-1351
Practice Address - Street 1:5220 S 6TH STREET RD
Practice Address - Street 2:SUITE 1500
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5735
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-747-1351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-11
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)