Provider Demographics
NPI:1619109543
Name:PHYSICIAN SERVICES CORP OF SOUTHERN ILLINOIS
Entity Type:Organization
Organization Name:PHYSICIAN SERVICES CORP OF SOUTHERN ILLINOIS
Other - Org Name:ST MARYS GOOD SAMARITAN MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCIAL DEVELOPMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-241-2204
Mailing Address - Street 1:413 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-3649
Mailing Address - Country:US
Mailing Address - Phone:618-532-3950
Mailing Address - Fax:618-532-9365
Practice Address - Street 1:1250 W WHITTAKER ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1917
Practice Address - Country:US
Practice Address - Phone:618-532-3950
Practice Address - Fax:618-532-9365
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICAN SEVICES CORP OF SOUTHERN ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL148998Medicare Oscar/Certification