Provider Demographics
NPI:1659475879
Name:SOUTHERN ILLINOIS SURGICAL APPLIANCE CO
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS SURGICAL APPLIANCE CO
Other - Org Name:SISA HOME MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-932-3157
Mailing Address - Street 1:19 WEST FRANKFORT PLAZA
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896
Mailing Address - Country:US
Mailing Address - Phone:618-932-3157
Mailing Address - Fax:618-932-3031
Practice Address - Street 1:207 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:DUQUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832
Practice Address - Country:US
Practice Address - Phone:618-542-3876
Practice Address - Fax:618-542-6157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIN PROCESS332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========007Medicaid