Provider Demographics
NPI:1972843613
Name:SOUTHERN ILLINOIS FAMILY FOOT CARE, LLC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS FAMILY FOOT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:618-244-3668
Mailing Address - Street 1:221 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2941
Mailing Address - Country:US
Mailing Address - Phone:618-244-3668
Mailing Address - Fax:
Practice Address - Street 1:221 N 27TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2941
Practice Address - Country:US
Practice Address - Phone:618-244-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-17
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003846261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1285744060Medicaid
IL1285744060Medicaid