Provider Demographics
NPI:1184494619
Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Entity type:Organization
Organization Name:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-757-8137
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:844-470-2488
Practice Address - Street 1:3220 ATLANTA ST STE 100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62707-8801
Practice Address - Country:US
Practice Address - Phone:217-545-4968
Practice Address - Fax:217-545-4444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-05
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care