Provider Demographics
NPI:1770259764
Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TEAM LEAD, MEDICAL STAFF
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:BURDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-545-6523
Mailing Address - Street 1:201 E MADISON ST STE 328
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5131
Mailing Address - Country:US
Mailing Address - Phone:217-545-6523
Mailing Address - Fax:
Practice Address - Street 1:1600 E CLEAR LAKE AVE STE 120
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-1172
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)