Provider Demographics
NPI:1720199748
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:RALPH
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-932-3157
Mailing Address - Street 1:PO BOX 1667
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0033
Mailing Address - Country:US
Mailing Address - Phone:618-529-2406
Mailing Address - Fax:618-351-7466
Practice Address - Street 1:1301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2227
Practice Address - Country:US
Practice Address - Phone:618-529-2406
Practice Address - Fax:618-351-7466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINIOIS SURGICAL APPLIANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2032-1120332B00000X, 332BC3200X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid
IL0251010002Medicare NSC