Provider Demographics
NPI:1578746228
Name:SOUTHERN ILLINOIS MEDICAL PLAZA SC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS MEDICAL PLAZA SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-529-1943
Mailing Address - Street 1:2250 REED STATION PKWY
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901
Mailing Address - Country:US
Mailing Address - Phone:618-529-1943
Mailing Address - Fax:618-549-2975
Practice Address - Street 1:2250 REED STATION PKWY
Practice Address - Street 2:STE 305
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3304
Practice Address - Country:US
Practice Address - Phone:618-529-1943
Practice Address - Fax:618-549-2975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007699111N00000X
IL036093859207Q00000X
225100000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03932090OtherBCBS OF IL GROUP
IL03932090OtherBCBS OF IL GROUP
ILIL1078Medicare UPIN