Provider Demographics
NPI:1982845137
Name:SOUTHERN ILLINOIS MEDICAL SERVICES, NFP
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS MEDICAL SERVICES, NFP
Other - Org Name:BENTON COMMUNITY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:REX
Authorized Official - Middle Name:P
Authorized Official - Last Name:BUDDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-5200
Mailing Address - Street 1:203 BAILEY LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1969
Mailing Address - Country:US
Mailing Address - Phone:618-438-5670
Mailing Address - Fax:618-438-5709
Practice Address - Street 1:203 BAILEY LN
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1969
Practice Address - Country:US
Practice Address - Phone:618-438-5670
Practice Address - Fax:618-438-5709
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN ILLINOIS HOSPITAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILXXXXXXXXX002Medicaid
ILXXXXXXXXX002Medicaid