Provider Demographics
NPI:1629190657
Name:SOUTHERN ILLINOIS NEUROLOGIC INSTITUTE
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS NEUROLOGIC INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:BURROWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-239-6660
Mailing Address - Street 1:100 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1427
Mailing Address - Country:US
Mailing Address - Phone:618-239-6660
Mailing Address - Fax:618-239-6662
Practice Address - Street 1:100 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1427
Practice Address - Country:US
Practice Address - Phone:618-239-6660
Practice Address - Fax:618-239-6662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36078383174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL130015602OtherRAILROAD MEDICARE
IL08207706OtherBLUE CROSS BLUE SHIELD
IL08207706OtherBLUE CROSS BLUE SHIELD
IL396510Medicare PIN