Provider Demographics
NPI:1619127289
Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION INC
Other - Org Name:CHRISTIAN ACTIVITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
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 1:8080 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62203-1808
Mailing Address - Country:US
Mailing Address - Phone:618-397-3303
Mailing Address - Fax:618-397-7802
Practice Address - Street 1:540 N 6TH ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-1320
Practice Address - Country:US
Practice Address - Phone:618-397-3303
Practice Address - Fax:618-397-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty