Provider Demographics
NPI:1740421536
Name:PHYSICIAN SERVICES CORP OF SOUTHERN ILLINOIS
Entity Type:Organization
Organization Name:PHYSICIAN SERVICES CORP OF SOUTHERN ILLINOIS
Other - Org Name:ST MARYS GOOD SAMARITAN MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MNG
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-436-6267
Mailing Address - Street 1:430 N PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3006
Mailing Address - Country:US
Mailing Address - Phone:618-532-9350
Mailing Address - Fax:
Practice Address - Street 1:430 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3006
Practice Address - Country:US
Practice Address - Phone:618-532-9350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIAN SERVICES CORP OF SOUTHERN ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-09
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116791207V00000X
IL002642261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1831101807OtherCMS GRP NPI
IL1831101807OtherCMS GRP NPI