Provider Demographics
NPI:1689636888
Name:SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS CORP SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-842-4470
Mailing Address - Street 1:209 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1218
Mailing Address - Country:US
Mailing Address - Phone:618-842-4470
Mailing Address - Fax:618-842-3437
Practice Address - Street 1:33 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:IL
Practice Address - Zip Code:62806-1006
Practice Address - Country:US
Practice Address - Phone:618-842-4470
Practice Address - Fax:618-842-3437
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS PRIMARY CARE ASSOCIATES, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-04
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060009133207Q00000X, 207R00000X, 207V00000X, 208000000X, 363A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6280601Medicaid
IL143848Medicare Oscar/Certification
IL=========6280601Medicaid