Provider Demographics
NPI:1659632602
Name:SI MEDICAL, INC.
Entity Type:Organization
Organization Name:SI MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ASKARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-993-6641
Mailing Address - Street 1:1909 W COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1097
Mailing Address - Country:US
Mailing Address - Phone:618-997-5677
Mailing Address - Fax:618-998-1451
Practice Address - Street 1:1909 W COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1097
Practice Address - Country:US
Practice Address - Phone:618-997-5677
Practice Address - Fax:618-998-1451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003714133VN1006X
IL85.003452363AM0700X
IL209.002243363LP2300X
IL209.005527363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty