Provider Demographics
NPI: | 1558385989 |
---|---|
Name: | SIU PHYSICIANS & SURGEONS, INC |
Entity Type: | Organization |
Organization Name: | SIU PHYSICIANS & SURGEONS, INC |
Other - Org Name: | SIU HEALTHCARE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | ASST MGR, MEDICAL STAFF SERVICES |
Authorized Official - Prefix: | |
Authorized Official - First Name: | SHELBY |
Authorized Official - Middle Name: | RENEE |
Authorized Official - Last Name: | BURDICK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 217-545-6523 |
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: | 217-545-8000 |
Mailing Address - Fax: | 844-470-2488 |
Practice Address - Street 1: | 201 E MADISON ST STE 328 |
Practice Address - Street 2: | |
Practice Address - City: | SPRINGFIELD |
Practice Address - State: | IL |
Practice Address - Zip Code: | 62702-5131 |
Practice Address - Country: | US |
Practice Address - Phone: | 217-545-8000 |
Practice Address - Fax: | 844-470-2488 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-27 |
Last Update Date: | 2024-01-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 207N00000X, 207ND0101X, 207Q00000X, 207R00000X, 207RE0101X, 207RG0100X, 2084P0800X, 208M00000X | |
207RA0201X, 207RR0500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
No | 207ND0101X | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | Group - Multi-Specialty |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RA0201X | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 0001558385989 | Medicaid | |
IL | CB2589 | Other | RR MEDICARE |
IL | CE8689 | Other | RR MEDICARE |
IL | CE8688 | Other | RR MEDICARE |
IL | CE8686 | Other | RR MEDICARE |
IL | CE8931 | Other | RR MEDICARE |
IL | CE8687 | Other | RR MEDICARE |
IL | CE8687 | Other | RR MEDICARE |
IL | CB2589 | Other | RR MEDICARE |
IL | 256515 | Medicare PIN | |
IL | 256510 | Medicare PIN | |
IL | 256514 | Medicare PIN | |
IL | 256512 | Medicare PIN |