Provider Demographics
NPI:1609813500
Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Other - Org Name:CENTREVILLE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-332-0694
Mailing Address - Street 1:2041 GOOSE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SAUGET
Mailing Address - State:IL
Mailing Address - Zip Code:62206-2822
Mailing Address - Country:US
Mailing Address - Phone:618-332-0953
Mailing Address - Fax:618-397-7802
Practice Address - Street 1:6000 BOND AVE
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62207-2328
Practice Address - Country:US
Practice Address - Phone:618-332-2740
Practice Address - Fax:618-332-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid
IL141856Medicare Oscar/Certification
IL732740Medicare PIN