Provider Demographics
NPI:1689991291
Name:PSYCHIATRIC SERVICES OF SOUTHERN ILLINOIS, LLC
Entity Type:Organization
Organization Name:PSYCHIATRIC SERVICES OF SOUTHERN ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHALFANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:618-236-6501
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 990
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-236-6501
Mailing Address - Fax:618-236-6551
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 990
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-236-6501
Practice Address - Fax:618-236-6551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK25958OtherMEDICARE ID
ILK25958OtherMEDICARE ID