Provider Demographics
NPI:1780688671
Name:PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC
Entity Type:Organization
Organization Name:PHYSICIAN SERVICES CORPORATION OF SOUTHERN ILLINOIS INC
Other - Org Name:SSM HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE MEDICAL GROUP
Authorized Official - Prefix:MR
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:EVISCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-899-1040
Mailing Address - Street 1:1411 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-0001
Mailing Address - Country:US
Mailing Address - Phone:618-532-9050
Mailing Address - Fax:618-532-9365
Practice Address - Street 1:1441 W BROADWAY
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-0001
Practice Address - Country:US
Practice Address - Phone:618-532-9050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0002642261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1831101807OtherNPI PSCSI GRP
IL1831101807OtherNPI PSCSI GRP
IL1831101807OtherNPI PSCSI GRP