Provider Demographics
NPI:1679844468
Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS HEALTHCARE FOUNDATION, INC.
Other - Org Name:WEBER MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
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 1:2041 GOOSE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SAUGET
Mailing Address - State:IL
Mailing Address - Zip Code:62206-2822
Mailing Address - Country:US
Mailing Address - Phone:618-332-0953
Mailing Address - Fax:618-332-2487
Practice Address - Street 1:1200 N EAST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2432
Practice Address - Country:US
Practice Address - Phone:618-395-2223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
207Q00000X, 207R00000X, 207V00000X, 208000000X, 2084P0800X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14-1156OtherNGS MEDICARE
IL14-1156OtherNGS MEDICARE