Provider Demographics
NPI:1134530173
Name:SOUTHERN ILLINOIS MEDICAL SPECIALISTS, LLC
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS MEDICAL SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:BEE
Authorized Official - Suffix:
Authorized Official - Credentials:DO, FACOI
Authorized Official - Phone:618-625-2105
Mailing Address - Street 1:107 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SESSER
Mailing Address - State:IL
Mailing Address - Zip Code:62884-1456
Mailing Address - Country:US
Mailing Address - Phone:618-625-2105
Mailing Address - Fax:618-625-2108
Practice Address - Street 1:107 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SESSER
Practice Address - State:IL
Practice Address - Zip Code:62884-1456
Practice Address - Country:US
Practice Address - Phone:618-625-2105
Practice Address - Fax:618-625-2108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036125672202C00000X, 204D00000X, 208VP0014X, 261QP2300X, 207R00000X
IL14D2034829291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036125672Medicaid
IL36125672Medicare PIN