Provider Demographics
NPI:1851731640
Name:SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:VERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-545-0193
Mailing Address - Street 1:701 NORTH FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:ROOM D443
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3757
Practice Address - Country:US
Practice Address - Phone:217-545-0193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125063931284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital